Provider Demographics
NPI:1487682662
Name:JACOBSON, EARL (DPM)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:EARL
Other - Middle Name:
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LTD
Mailing Address - Street 1:3650 S EASTERN AVE
Mailing Address - Street 2:# 200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3345
Mailing Address - Country:US
Mailing Address - Phone:702-384-2544
Mailing Address - Fax:702-384-8528
Practice Address - Street 1:3650 S EASTERN AVE
Practice Address - Street 2:# 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3345
Practice Address - Country:US
Practice Address - Phone:702-384-2544
Practice Address - Fax:702-384-8528
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV43213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002102804Medicaid
756480688OtherPALMETTO GBA RAILROAD MED
NV002102804Medicaid
880182354OtherEIN
NV0821300001Medicare NSC