Provider Demographics
NPI:1780617639
Name:JACOBUCCI, NICOLA JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:NICOLA
Middle Name:JOSEPH
Last Name:JACOBUCCI
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:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:418-420 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-965-2273
Practice Address - Fax:718-965-2275
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-01772207Q00000X
NY296566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1087MOtherBCBS
NCC45800Medicare UPIN
NC080122381OtherRR MEDICARE
NC891087MMedicaid
NC2247502Medicare PIN
NCNC0285AMedicare PIN
NC1212660021OtherDME