Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 046007399 | IL |
NPI | 1255326500 |
---|---|
Provider Name | Dr. Paul Christopher Jacobs |
First Address | Carbondale, IL 62901-1018 |
Second Address | Carbondale, IL 62901-1018 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2005 |
Last Update Date | 09/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
410002083 | RAILROAD MEDICARE PTAN (01) | |
410048999 | RAILROAD MEDICARE PTAN (01) | |
T37858 | (02) | IL |