Provider Demographics
NPI:1619000486
Name:JACOBS, GORDON W (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:W
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 1:14920 WYNDHAM OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1512
Mailing Address - Country:US
Mailing Address - Phone:704-543-8236
Mailing Address - Fax:
Practice Address - Street 1:14920 WYNDHAM OAKS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1512
Practice Address - Country:US
Practice Address - Phone:704-543-8236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33382208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC130799Medicaid
NC89-45688Medicaid
213260Medicare ID - Type Unspecified
NC89-45688Medicaid