Provider Demographics
NPI:1558369702
Name:JACOBSON, STEVEN D (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:338 CAMELLIA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4508
Mailing Address - Country:US
Mailing Address - Phone:314-397-9831
Mailing Address - Fax:
Practice Address - Street 1:25A JUNE ST STE 111
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2642
Practice Address - Country:US
Practice Address - Phone:207-324-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100177207R00000X
ME27201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110230748OtherCHAMPUS
MO110230748OtherRAILROAD MEDICARE
MO100236OtherGROUP HEALTH PLAN
MO10292OtherBLUE CROSS/BLUE SHIELD
MO171748OtherHEALTHLINK
MO100236OtherGROUP HEALTH PLAN
MO110230748OtherRAILROAD MEDICARE