Provider Demographics
NPI:1467410464
Name:JACOBS, ALLEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:T
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:855-979-5700
Mailing Address - Fax:855-979-5701
Practice Address - Street 1:2675 WINKLER AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9342
Practice Address - Country:US
Practice Address - Phone:855-979-5700
Practice Address - Fax:855-979-5701
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23107UMedicare ID - Type Unspecified
FLF43312Medicare UPIN