Provider Demographics
NPI:1861568412
Name:JACOBS, LEE DAVID (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:DAVID
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 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:
Practice Address - Street 1:6875 DOUGLAS BLVD STE A
Practice Address - Street 2:KAISER PERMANENTE DOUGLASVILLE
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7155
Practice Address - Country:US
Practice Address - Phone:678-838-2246
Practice Address - Fax:770-431-4350
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028283207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40239Medicare UPIN
11BDDTXMedicare ID - Type Unspecified