Provider Demographics
NPI:1962488577
Name:JACOBSON, ROY HARDY (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:HARDY
Last Name:JACOBSON
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 1:2830 VICTORY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1786
Mailing Address - Country:US
Mailing Address - Phone:513-245-3052
Mailing Address - Fax:
Practice Address - Street 1:305 CRESCENT AVE
Practice Address - Street 2:UNIVERSITY WYOMING FAMILY PRACTICE CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-4406
Practice Address - Country:US
Practice Address - Phone:513-821-0275
Practice Address - Fax:513-821-3621
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.071001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2013823Medicaid
G47047Medicare UPIN
OHJA4100994Medicare PIN
OHJA4100993Medicare PIN
OH2013823Medicaid