Provider Demographics
NPI:1760619910
Name:DANIEL M JACOBS MD PA
Entity Type:Organization
Organization Name:DANIEL M JACOBS MD PA
Other - Org Name:PROPATHMED LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-895-2862
Mailing Address - Street 1:2200 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2252
Mailing Address - Country:US
Mailing Address - Phone:414-258-9511
Mailing Address - Fax:414-607-3946
Practice Address - Street 1:458 W HILLSBORO BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1604
Practice Address - Country:US
Practice Address - Phone:954-895-2862
Practice Address - Fax:414-607-3946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-15
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800025654291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00921513OtherRR MEDICARE
FLP00921513OtherRR MEDICARE