Provider Demographics
NPI:1538204326
Name:JACOBS, GARY JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E. ESPLANADE DR
Mailing Address - Street 2:SUITE 560
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036
Mailing Address - Country:US
Mailing Address - Phone:805-485-5831
Mailing Address - Fax:805-485-5657
Practice Address - Street 1:300 E ESPLANADE DR
Practice Address - Street 2:SUITE 560
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-1238
Practice Address - Country:US
Practice Address - Phone:805-485-5831
Practice Address - Fax:805-485-5657
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6057 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060570Medicaid
CA6178660001Medicare NSC
CAU28642Medicare UPIN
CASD0060570Medicaid
CAWOP6057AMedicare PIN
CA1922298702Medicare NSC