Provider Demographics
NPI:1073681623
Name:JACOBS, GARY P (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:P
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 1:3432 GURNARD AVE
Mailing Address - Street 2:SAN PEDRO
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4716
Mailing Address - Country:US
Mailing Address - Phone:310-386-4200
Mailing Address - Fax:
Practice Address - Street 1:14560 MAGNOLIA ST STE 101
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4791
Practice Address - Country:US
Practice Address - Phone:714-889-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist