Provider Demographics
NPI:1053391748
Name:JACOBS, STEPHEN B (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
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 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-523-3649
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:259 MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6723
Practice Address - Country:US
Practice Address - Phone:207-846-9602
Practice Address - Fax:207-523-8586
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011883208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEG86876Medicare UPIN
MEMM762601Medicare PIN
MEMM7626Medicare ID - Type Unspecified