Provider Demographics
NPI:1164457859
Name:JACOBSON, PHILIP (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
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 1:461 RANCH RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1755
Mailing Address - Country:US
Mailing Address - Phone:954-530-4005
Mailing Address - Fax:
Practice Address - Street 1:4161 NW 5TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2101
Practice Address - Country:US
Practice Address - Phone:954-585-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 70215207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G15140Medicare UPIN
FL31912Medicare ID - Type Unspecified