Provider Demographics
NPI:1992898100
Name:JACOBSON, MARK E (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3409 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-1049
Mailing Address - Country:US
Mailing Address - Phone:718-231-9000
Mailing Address - Fax:718-405-9626
Practice Address - Street 1:3409 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1049
Practice Address - Country:US
Practice Address - Phone:718-231-9000
Practice Address - Fax:718-405-9626
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT33555-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist