Provider Demographics
NPI:1265649966
Name:JACOBSEN, GARTH R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARTH
Middle Name:R
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2S661 AVE NORMANDY W
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-271-1363
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DRIVE
Practice Address - Street 2:#8220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8220
Practice Address - Country:US
Practice Address - Phone:619-543-6711
Practice Address - Fax:619-543-5869
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA99668208600000X
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery