Provider Demographics
NPI:1760551915
Name:JACOBSON, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5198
Mailing Address - Country:US
Mailing Address - Phone:619-286-6930
Mailing Address - Fax:619-286-9438
Practice Address - Street 1:5555 RESERVOIR DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5198
Practice Address - Country:US
Practice Address - Phone:619-286-6930
Practice Address - Fax:619-286-9438
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71151207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G711510Medicaid
CA990010759OtherMEDICARE RR
CA00G711510Medicaid