MEDICARE: STANLEY JACOBS, M.D. INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	G65799	CA

General Provider Information

NPI Number	:	1447593066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANLEY JACOBS, M.D. INC

Provider Business Mailing Address
First Line	:	PO BOX 6671
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95406-0671
Country	:	US
Telephone Number	:	707-433-0220
Fax Number	:	707-473-0990

Provider Business Practice Location Address
First Line	:	145 FOSS CREEK CIR
Second Line	:
City	:	HEALDSBURG
State	:	CA
Zip	:	95448-4288
Country	:	US
Telephone Number	:	707-473-0220
Fax Number	:	707-473-0990

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STANLEY JACOBS
Credential	:	M,D,
Telephone Number	:	707-473-0220

Provider Enumeration Date	:	04/02/2013
Last Update Date	:	04/02/2013

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