Healthcare Provider Details

I. General information

NPI: 1760551915
Provider Name (Legal Business Name): MARK DAVID JACOBSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR STE 104
SAN DIEGO CA
92120-5198
US

IV. Provider business mailing address

5555 RESERVOIR DR STE 104
SAN DIEGO CA
92120-5198
US

V. Phone/Fax

Practice location:
  • Phone: 619-286-6930
  • Fax: 619-286-9438
Mailing address:
  • Phone: 619-286-6930
  • Fax: 619-286-9438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberG71151
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG71151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: