Provider Demographics
NPI:1366442600
Name:JACOBSON, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:901 ENTERPRISE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6249
Mailing Address - Country:US
Mailing Address - Phone:757-825-2500
Mailing Address - Fax:757-825-2500
Practice Address - Street 1:5408 DISCOVERY PARK BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2893
Practice Address - Country:US
Practice Address - Phone:757-253-8722
Practice Address - Fax:757-253-8726
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101233611207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006503446Medicaid
VA006503489Medicaid
VA006503489Medicaid
VAP00009432Medicare PIN
VA006503446Medicaid