Provider Demographics
NPI:1174605372
Name:JACOBY, BRADLEY G (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:G
Last Name:JACOBY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7170 HIGHWAY 278
Mailing Address - Street 2:SUITE B
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014
Mailing Address - Country:US
Mailing Address - Phone:770-787-6200
Mailing Address - Fax:770-787-2643
Practice Address - Street 1:7170 HIGHWAY 278
Practice Address - Street 2:STE B
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:770-787-6200
Practice Address - Fax:770-787-2643
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-08-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA027835207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000326697BMedicaid
C68884Medicare UPIN
GA000326697BMedicaid