Provider Demographics
NPI:1306894423
Name:JACOBSON, MARK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:922 SHORE ACRES DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-9269
Mailing Address - Country:US
Mailing Address - Phone:352-261-5502
Mailing Address - Fax:352-261-5504
Practice Address - Street 1:769 HIGHWAY 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6340
Practice Address - Country:US
Practice Address - Phone:352-261-5502
Practice Address - Fax:352-350-5942
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME671582085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376466400Medicaid
FL376466400Medicaid
FL26312TMedicare PIN
FL26312UMedicare PIN
FL26312XMedicare PIN
KY7100145430Medicaid
FL26312RMedicare PIN