Provider Demographics
NPI:1376915066
Name:ALLYN JACOBSON OD PA
Entity Type:Organization
Organization Name:ALLYN JACOBSON OD PA
Other - Org Name:ALLYN JACOBSOM OD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLYN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-238-2121
Mailing Address - Street 1:9529 SW 160TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3350
Mailing Address - Country:US
Mailing Address - Phone:305-238-2121
Mailing Address - Fax:305-238-2123
Practice Address - Street 1:9529 SW 160TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-3350
Practice Address - Country:US
Practice Address - Phone:305-238-2121
Practice Address - Fax:305-238-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty