Provider Demographics
NPI:1255326500
Name:JACOBS, PAUL CHRISTOPHER (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CHRISTOPHER
Last Name:JACOBS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N BEADLE DR
Mailing Address - Street 2:SUITE 40
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1018
Mailing Address - Country:US
Mailing Address - Phone:618-529-4817
Mailing Address - Fax:618-351-9024
Practice Address - Street 1:1001 N BEADLE DR
Practice Address - Street 2:SUITE 40
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1018
Practice Address - Country:US
Practice Address - Phone:618-529-4817
Practice Address - Fax:618-351-9024
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007399152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
410048999OtherRAILROAD MEDICARE PTAN
410002083OtherRAILROAD MEDICARE PTAN
410048999OtherRAILROAD MEDICARE PTAN
ILT37858Medicare UPIN
IL688832Medicare ID - Type Unspecified