Provider Demographics
NPI:1134183726
Name:JACOBS, EDWARD R (OD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:R
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 1:999 RIVERVIEW DRIVE
Mailing Address - Street 2:STE 203
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512
Mailing Address - Country:US
Mailing Address - Phone:973-785-4499
Mailing Address - Fax:973-785-4699
Practice Address - Street 1:999 RIVERVIEW DRIVE
Practice Address - Street 2:STE 203
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512
Practice Address - Country:US
Practice Address - Phone:973-785-4499
Practice Address - Fax:973-785-4699
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4258152W00000X
NJ181152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
U01621Medicare UPIN