Provider Demographics
NPI:1700890563
Name:JACOBS, HARVEY RICHARD (DPM)
Entity Type:Individual
Prefix:MR
First Name:HARVEY
Middle Name:RICHARD
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CLYDE ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5038
Mailing Address - Country:US
Mailing Address - Phone:732-873-1111
Mailing Address - Fax:732-873-1113
Practice Address - Street 1:25 CLYDE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5038
Practice Address - Country:US
Practice Address - Phone:732-873-1111
Practice Address - Fax:732-873-1113
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00105100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1240307Medicaid
T73087Medicare PIN
NJ1240307Medicaid
NJ4124250001Medicare NSC