Provider Demographics
NPI:1679533186
Name:JACOBS, MARK MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
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 1:3553 WHIPPLE ROAD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1507
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:415-499-4213
Practice Address - Street 1:3553 WHIPPLE ROAD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:415-499-4213
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45317207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG45317OtherCA STATE LICENSE NUMBER
CA00G453170Medicaid
CA00G453170Medicare PIN
CA00G453170Medicaid