Provider Demographics
NPI:1760467484
Name:JACOBSON, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
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 1:2561 LANDER RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4317
Mailing Address - Country:US
Mailing Address - Phone:440-461-5666
Mailing Address - Fax:
Practice Address - Street 1:36100 EUCLID AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4456
Practice Address - Country:US
Practice Address - Phone:440-946-9555
Practice Address - Fax:440-946-2223
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048289207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0602351Medicaid
OHA16054Medicare UPIN
OH0602351Medicaid