Provider Demographics
NPI:1255330676
Name:JACOBS, EDWARD CORNELIOUS (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CORNELIOUS
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-752-2305
Mailing Address - Fax:
Practice Address - Street 1:10 SOUTHMOOR CIR NW
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2486
Practice Address - Country:US
Practice Address - Phone:937-294-1489
Practice Address - Fax:937-297-6468
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16625174400000X
ME014971174400000X
MA32702174400000X
OH35-07-3367-J174400000X
OH35073367208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2033007Medicaid
OHJA0836796Medicare PIN
OHH444050Medicare PIN
OH0836795Medicare PIN
OHA39849Medicare UPIN