Provider Demographics
NPI:1770578346
Name:JACOBS, WILLIAM ANTHONY (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ANTHONY
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13005 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9206
Mailing Address - Country:US
Mailing Address - Phone:561-790-4444
Mailing Address - Fax:561-790-4237
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:SUITE 213
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-790-4444
Practice Address - Fax:561-790-4237
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82996OtherBCBS
FLD85817Medicare UPIN
FL82996AMedicare ID - Type Unspecified