Provider Demographics
NPI:1548285604
Name:JACOBS, MARTIN D (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:D
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 INTERSTATE PKWY
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2935
Mailing Address - Country:US
Mailing Address - Phone:814-362-4031
Mailing Address - Fax:
Practice Address - Street 1:652 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2935
Practice Address - Country:US
Practice Address - Phone:814-362-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD023198E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006809170001Medicaid
PA084042Medicare ID - Type Unspecified
PA0006809170001Medicaid