Provider Demographics
NPI:1194721498
Name:JACOBS, BRADLEY EDGAR (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:EDGAR
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 1:2927 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4005
Mailing Address - Country:US
Mailing Address - Phone:336-765-9350
Mailing Address - Fax:336-760-4255
Practice Address - Street 1:2927 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4005
Practice Address - Country:US
Practice Address - Phone:336-765-9350
Practice Address - Fax:336-760-4255
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801681207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891280KMedicaid
NC1280KOtherBCBS
NC2284132Medicare PIN
H32572Medicare UPIN
NC2284132Medicare ID - Type Unspecified