Healthcare Provider Details

I. General information

NPI: 1760619910
Provider Name (Legal Business Name): DANIEL M JACOBS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 W HILLSBORO BLVD
DEERFIELD BEACH FL
33441-1604
US

IV. Provider business mailing address

2200 NORTH MAYFAIR ROAD SUITE 200
WAUWATOSA WI
53226-2252
US

V. Phone/Fax

Practice location:
  • Phone: 954-895-2862
  • Fax: 414-607-3946
Mailing address:
  • Phone: 414-258-9511
  • Fax: 414-607-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number800025654
License Number StateFL

VIII. Authorized Official

Name: DR. DANIEL M JACOBS
Title or Position: OWNER
Credential: MD
Phone: 954-895-2862