Provider Demographics
NPI:1669465274
Name:JACOBSON, HAL M (MD)
Entity Type:Individual
Prefix:
First Name:HAL
Middle Name:M
Last Name:JACOBSON
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:PO BOX 864460
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-0001
Mailing Address - Country:US
Mailing Address - Phone:352-243-9709
Mailing Address - Fax:352-243-8703
Practice Address - Street 1:1920 DON WICKHAM DR
Practice Address - Street 2:SUITE130
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1918
Practice Address - Country:US
Practice Address - Phone:352-243-9709
Practice Address - Fax:352-243-8703
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00387362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068606900Medicaid
FL110028619OtherRR MEDICARE LEESBURG
FL68328AMedicare PIN
D57864Medicare UPIN
FL068606900Medicaid
FL68328ZMedicare PIN