Healthcare Provider Details

I. General information

NPI: 1811975873
Provider Name (Legal Business Name): WAYNE E JACOBS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 S MARYLAND PKWY SUITE 102
LAS VEGAS NV
89109-2298
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 202
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-2888
  • Fax: 702-696-9289
Mailing address:
  • Phone: 877-406-2916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number7655
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: