MEDICARE: DR. LEONARD JACOBY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC001879	FL
2	152W00000X	Optometrist	856	TN
3	152W00000X	Optometrist	3053	TX

General Provider Information

NPI Number	:	1932274255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEONARD JACOBY O.D.

Provider Business Mailing Address
First Line	:	352 WOODSTEAD CIR
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-3726
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 E ALTAMONTE DR
Second Line	:	SPACE 2119
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32701-4613
Country	:	US
Telephone Number	:	407-831-1330
Fax Number	:	407-831-2016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	07/08/2007

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