Healthcare Provider Details

I. General information

NPI: 1982631404
Provider Name (Legal Business Name): PAUL ERIC JACOBSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 NE 167TH ST SUITE 102
NORTH MIAMI BEACH FL
33162-3400
US

IV. Provider business mailing address

152 NE 167TH ST SUITE 102
NORTH MIAMI BEACH FL
33162-3400
US

V. Phone/Fax

Practice location:
  • Phone: 305-945-5437
  • Fax: 305-945-0173
Mailing address:
  • Phone: 305-945-5437
  • Fax: 305-945-0173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS4671
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: