Provider Demographics
NPI:1962400135
Name:JACOBSON, RANDALL K (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:K
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:427 S BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2509
Mailing Address - Country:US
Mailing Address - Phone:509-456-0107
Mailing Address - Fax:509-747-2635
Practice Address - Street 1:427 S BERNARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2509
Practice Address - Country:US
Practice Address - Phone:509-456-0107
Practice Address - Fax:509-747-2635
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036964207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAJA7856OtherASURIS(REGENCE NW HEALTH)
IDKM646OtherBLUE CROSS OF ID
WAA025OtherTRICARE
ID000010005537OtherASURIS(REGENCE BS OF ID)
WA125850OtherLABOR AND INDUSTRIES
WA17297OtherGROUP HEALTH
WAWA0690OtherNORTHWEST BENEFIT NETWORK
WA8239758Medicaid
WA125850OtherLABOR AND INDUSTRIES
WA8239758Medicaid