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General NPI Number Information
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NPI Number | 1578961843
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Entity Type | Organization
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Legal Business Name | STUART I JACOBS MD, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 12/18/2014
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Last Update Date | 03/30/2015
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Provider Practice Location Address
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Address Line | 5345 N EL DORADO ST SUITE 12
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City | STOCKTON
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State | CA
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Zip | 95207-5872
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Country | US
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Telephone | 209-957-6662
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Fax | 209-957-0310
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Provider Business Mailing Address
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Address Line | 5345 N EL DORADO ST SUITE 12
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City | STOCKTON
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State | CA
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Zip | 95207-5872
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Country | US
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Telephone | 209-957-6662
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Fax | 209-957-0310
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Authorized Official
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Title or Position | PRESIDENT OF CORPORATION
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Name | STUART I JACOBS
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Credential | MD
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Telephone | 209-957-6662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | G30790
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License Number State | CA
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