=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760690135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY LEONARD JACOBS OPTICIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13132 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-4858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-0410
-----------------------------------------------------
Fax | 352-597-0420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6316 BAYSIDE DR
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-2038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-845-8112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO3669
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------