Provider Demographics
NPI:1053399691
Name:JACOBSON, RICHARD Y (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:Y
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 2ND AVE N
Mailing Address - Street 2:MEDICAL ARTS BLDG
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-4119
Mailing Address - Country:US
Mailing Address - Phone:515-573-1145
Mailing Address - Fax:515-573-1028
Practice Address - Street 1:1428 2ND AVE N
Practice Address - Street 2:MEDICAL ARTS BLDG
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4119
Practice Address - Country:US
Practice Address - Phone:515-573-1145
Practice Address - Fax:515-573-1028
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07134OtherBC/BS
IA3066183Medicaid
IAIB1233001OtherMEDICARE ID - TYPE UNSPECIFIED
IA3066183Medicaid
IA6153780001Medicare NSC
IAT00568Medicare UPIN