Provider Demographics
NPI:1598772378
Name:JACOBSON, MARK STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:30 N UNION ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1345
Mailing Address - Country:US
Mailing Address - Phone:585-232-2560
Mailing Address - Fax:585-232-6446
Practice Address - Street 1:30 N UNION ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1345
Practice Address - Country:US
Practice Address - Phone:585-232-2560
Practice Address - Fax:585-232-6446
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY206578-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0308OtherEXCELLUS BLUE SHIELD
NY10102CROtherPREFERRED CARE
NY4303445OtherAETNA
NY01735840Medicaid
NY10102CROtherPREFERRED CARE
NY31536HMedicare ID - Type Unspecified