Provider Demographics
NPI:1336208651
Name:JACOBSON, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
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 1:1 PERRYRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4607
Mailing Address - Country:US
Mailing Address - Phone:203-869-8353
Mailing Address - Fax:203-869-4004
Practice Address - Street 1:1 PERRYRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4607
Practice Address - Country:US
Practice Address - Phone:203-869-8353
Practice Address - Fax:203-869-4004
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010022707CT02OtherBLUE CROSS PROVIDER NUMBE
CT010022707CT02OtherBLUE CROSS PROVIDER NUMBE
CT160002237Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER