Provider Demographics
NPI:1700852878
Name:JACOBY, RUSSELL F (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:F
Last Name:JACOBY
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 1:3108 PONTE MORINO DRIVE
Mailing Address - Street 2:PALMER PROFESSIONAL CENTRE SUITE 230
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-5022
Mailing Address - Country:US
Mailing Address - Phone:530-672-2701
Mailing Address - Fax:530-672-9097
Practice Address - Street 1:3108 PONTE MORINO DRIVE
Practice Address - Street 2:PALMER PROFESSIONAL CENTRE SUITE 230
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-5022
Practice Address - Country:US
Practice Address - Phone:530-672-2701
Practice Address - Fax:530-672-9097
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI32200207RG0100X
CAG86695207RG0100X
IL36071501207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31708100Medicaid
WI31708100Medicaid