Provider Demographics
NPI:1578961843
Name:STUART I JACOBS MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:STUART I JACOBS MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:I
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-957-6662
Mailing Address - Street 1:5345 N EL DORADO ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5872
Mailing Address - Country:US
Mailing Address - Phone:209-957-6662
Mailing Address - Fax:209-957-0310
Practice Address - Street 1:5345 N EL DORADO ST
Practice Address - Street 2:SUITE 12
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5872
Practice Address - Country:US
Practice Address - Phone:209-957-6662
Practice Address - Fax:209-957-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30790207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44548Medicare UPIN