Provider Demographics
NPI:1821101684
Name:JACOBS, MICHAEL E (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:JACOBS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 FIVE CITIES DR
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3005
Mailing Address - Country:US
Mailing Address - Phone:805-773-4700
Mailing Address - Fax:805-773-4248
Practice Address - Street 1:573 FIVE CITIES DR
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3005
Practice Address - Country:US
Practice Address - Phone:805-773-4700
Practice Address - Fax:805-773-4248
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7230 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0072300Medicaid
CASD0072300Medicaid
CAOP7230Medicare ID - Type Unspecified
CA0402140001Medicare NSC