Healthcare Provider Details

I. General information

NPI: 1043291511
Provider Name (Legal Business Name): ROBERT W JACEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 TRAIN LN
HEATHSVILLE VA
22473-4595
US

IV. Provider business mailing address

712 TRAIN LN
HEATHSVILLE VA
22473-4595
US

V. Phone/Fax

Practice location:
  • Phone: 804-517-5555
  • Fax: 804-737-9058
Mailing address:
  • Phone: 804-517-5555
  • Fax: 804-737-9058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101024617
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: