Provider Demographics
NPI:1922298702
Name:GARY J JACOBS, OD, INC
Entity Type:Organization
Organization Name:GARY J JACOBS, OD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-485-5831
Mailing Address - Street 1:300 E ESPLANADE DR
Mailing Address - Street 2:SUITE 560
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-1238
Mailing Address - Country:US
Mailing Address - Phone:805-485-5831
Mailing Address - Fax:805-485-5657
Practice Address - Street 1:300 E ESPLANADE DR
Practice Address - Street 2:SUITE 560
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-1238
Practice Address - Country:US
Practice Address - Phone:805-485-5831
Practice Address - Fax:805-485-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060570Medicaid
U28642Medicare UPIN
CASD0060570Medicaid