Provider Demographics
NPI:1376747808
Name:LESLIE W. JACOBSON, MD PA
Entity Type:Organization
Organization Name:LESLIE W. JACOBSON, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-927-7138
Mailing Address - Street 1:6533 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2103
Mailing Address - Country:US
Mailing Address - Phone:952-927-7138
Mailing Address - Fax:952-924-4021
Practice Address - Street 1:6533 DREW AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2103
Practice Address - Country:US
Practice Address - Phone:952-927-7138
Practice Address - Fax:952-924-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14592207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN767265900Medicaid
MNA95659Medicare UPIN
MN181610143Medicare ID - Type Unspecified