Provider Demographics
NPI:1184951857
Name:DAN G. JACOBSON, MD, PA
Entity type:Organization
Organization Name:DAN G. JACOBSON, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:772-286-1812
Mailing Address - Street 1:432 SE OSCEOLA ST
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2577
Mailing Address - Country:US
Mailing Address - Phone:772-286-1812
Mailing Address - Fax:772-288-4784
Practice Address - Street 1:432 SE OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2577
Practice Address - Country:US
Practice Address - Phone:772-286-1812
Practice Address - Fax:772-288-4784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01280OtherBLUE CROSS BLUE SHIELD OF FLORIDA AND VERY OLD MEDICARE ISSUED 041186