Provider Demographics
NPI:1184680258
Name:JACOBS, BRADLY P (MD)
Entity type:Individual
Prefix:
First Name:BRADLY
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 1:601 MURRAY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965
Mailing Address - Country:US
Mailing Address - Phone:415-339-2692
Mailing Address - Fax:415-339-2691
Practice Address - Street 1:601 MURRAY CIRCLE
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965
Practice Address - Country:US
Practice Address - Phone:415-339-2692
Practice Address - Fax:415-339-2691
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A604330Medicaid
CAG49275Medicare UPIN
CA00A604330Medicare PIN