Provider Demographics
NPI:1871689109
Name:JACOBS, IVAN H (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:H
Last Name:JACOBS
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 1:592 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1002
Mailing Address - Country:US
Mailing Address - Phone:908-789-8999
Mailing Address - Fax:908-789-1379
Practice Address - Street 1:592 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1002
Practice Address - Country:US
Practice Address - Phone:908-789-8999
Practice Address - Fax:908-789-1379
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA32702207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1817001Medicaid
NJ043261DAFMedicare ID - Type Unspecified
NJC57896Medicare UPIN