Provider Demographics
NPI:1053353029
Name:JACOBY, RICHARD MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:JACOBY
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-343-9800
Mailing Address - Fax:704-347-2011
Practice Address - Street 1:700 GARDEN VIEW CT STE 204
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2478
Practice Address - Country:US
Practice Address - Phone:760-452-6334
Practice Address - Fax:760-349-9755
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400849207RC0000X, 207RI0011X
CAG161416207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC45580OtherBCBS
NCP00612426OtherRAILROAD MEDICARE
CA1053353029OtherNPPES
SCN00849Medicaid
NC8945580Medicaid
SCF609085332Medicare ID - Type Unspecified
NC8945580Medicaid
NC2202127DMedicare PIN