Healthcare Provider Details

I. General information

NPI: 1700852878
Provider Name (Legal Business Name): RUSSELL F JACOBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3108 PONTE MORINO DRIVE PALMER PROFESSIONAL CENTRE SUITE 230
CAMERON PARK CA
95682-5022
US

IV. Provider business mailing address

3108 PONTE MORINO DRIVE PALMER PROFESSIONAL CENTRE SUITE 230
CAMERON PARK CA
95682-5022
US

V. Phone/Fax

Practice location:
  • Phone: 530-672-2701
  • Fax: 530-672-9097
Mailing address:
  • Phone: 530-672-2701
  • Fax: 530-672-9097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number32200
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG86695
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number36071501
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: