Provider Demographics
NPI:1417915190
Name:JACOBSON, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
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 1:15320 AMBERLY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1647
Mailing Address - Country:US
Mailing Address - Phone:813-977-0733
Mailing Address - Fax:813-971-2230
Practice Address - Street 1:500 VONDERBURG DR
Practice Address - Street 2:SUITE 303-E
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5964
Practice Address - Country:US
Practice Address - Phone:813-681-5702
Practice Address - Fax:813-653-2376
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
30134VMedicare ID - Type Unspecified
D53871Medicare UPIN