Provider Demographics
NPI:1811986763
Name:JACOBS, THEODORE R (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:R
Last Name:JACOBS
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 HARDY RD # 220
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-4915
Mailing Address - Country:US
Mailing Address - Phone:603-472-4711
Mailing Address - Fax:
Practice Address - Street 1:1 HARDY RD # 220
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-4915
Practice Address - Country:US
Practice Address - Phone:603-472-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8619207T00000X
GA64835207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106197AMedicaid
RE1790Medicare PIN
GA003106197AMedicaid