Provider Demographics
NPI:1285645036
Name:JACOBSON, MATTHEW WARNER (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WARNER
Last Name:JACOBSON
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-2400
Mailing Address - Country:US
Mailing Address - Phone:321-255-9671
Mailing Address - Fax:
Practice Address - Street 1:1304 OAK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3111
Practice Address - Country:US
Practice Address - Phone:321-723-4723
Practice Address - Fax:321-727-1448
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46162207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040640600Medicaid
FL050036584OtherRRMCR
FL05553OtherBCBSFL
FLD84881Medicare UPIN
FL05553ZMedicare ID - Type Unspecified