Provider Demographics
NPI:1093798316
Name:JACOBS, RANDALL S (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6202
Mailing Address - Fax:239-343-4159
Practice Address - Street 1:9800 S HEALTHPARK DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-6202
Practice Address - Fax:239-343-4159
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME164131207RG0100X
MI4301406898207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120521000Medicaid
MI2719618Medicaid
OM01690Medicare ID - Type Unspecified