Provider Demographics
NPI:1417975905
Name:JACOBS, RANDOLPH J (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:J
Last Name:JACOBS
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 1:23905 CLINTON KEITH RD STE 114
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7899
Mailing Address - Country:US
Mailing Address - Phone:951-672-7673
Mailing Address - Fax:951-672-1197
Practice Address - Street 1:23905 CLINTON KEITH RD STE 114
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7899
Practice Address - Country:US
Practice Address - Phone:951-672-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61654207N00000X, 207NI0002X, 207ND0900X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25046Medicare UPIN