Provider Demographics
NPI:1225184245
Name:JACOBS, CHARLOTTE D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:D
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 MIRADA AVE
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-8477
Mailing Address - Country:US
Mailing Address - Phone:650-725-8738
Mailing Address - Fax:650-498-4696
Practice Address - Street 1:875 BLAKE WILBUR DR
Practice Address - Street 2:CC2241
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2205
Practice Address - Country:US
Practice Address - Phone:650-725-8738
Practice Address - Fax:650-498-4696
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27593207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G275930Medicaid
CA00G275930Medicaid
CAA89455Medicare UPIN