Provider Demographics
NPI:1457333668
Name:JACOBS, RICHARD ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLEN
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 1:619 S. WASHINGTON ST.
Mailing Address - Street 2:STE 202
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0000
Mailing Address - Country:US
Mailing Address - Phone:208-882-1522
Mailing Address - Fax:208-882-1527
Practice Address - Street 1:619 S WASHINGTON ST
Practice Address - Street 2:STE 202
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3090
Practice Address - Country:US
Practice Address - Phone:208-882-1522
Practice Address - Fax:208-882-1527
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID362964260OtherTAX ID
IDA07242Medicare UPIN
ID362964260OtherTAX ID