Provider Demographics
NPI:1760845184
Name:JACOBSEN, BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:JACOBSEN
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:RETINA GROUP OF WASHINGTON
Mailing Address - Street 2:660 PENNSYLVANIA AVE. SE SUITE 200
Mailing Address - City:WASHINGTON DC
Mailing Address - State:DC
Mailing Address - Zip Code:20003
Mailing Address - Country:US
Mailing Address - Phone:202-331-1188
Mailing Address - Fax:
Practice Address - Street 1:7695 CARDINAL CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3357
Practice Address - Country:US
Practice Address - Phone:858-609-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA185917207WX0107X
UT10511526-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10511526-1205Medicaid