Provider Demographics
NPI:1760690135
Name:JACOBS, GARY LEONARD (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEONARD
Last Name:JACOBS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6316 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2038
Mailing Address - Country:US
Mailing Address - Phone:727-845-8112
Mailing Address - Fax:
Practice Address - Street 1:13132 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-4858
Practice Address - Country:US
Practice Address - Phone:352-597-0410
Practice Address - Fax:352-597-0420
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3669156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician