Provider Demographics
NPI:1639176894
Name:JACOBSEN, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:JACOBSEN
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 1:2400 E ARIZONA BILTMORE CIR
Mailing Address - Street 2:SUITE 2450
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2107
Mailing Address - Country:US
Mailing Address - Phone:602-212-0100
Mailing Address - Fax:602-279-1701
Practice Address - Street 1:2400 E ARIZONA BILTMORE CIR
Practice Address - Street 2:SUITE 2450
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2107
Practice Address - Country:US
Practice Address - Phone:602-212-0100
Practice Address - Fax:602-279-1701
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21620208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167850Medicaid
AZC87509Medicare ID - Type Unspecified
AZ21426Medicare UPIN