Basic Information
| Provider Information | |||||||||
| NPI: | 1053353029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043439800 | ||||||||
| FaxNumber: | 7043472011 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 GARDEN VIEW CT STE 204 | ||||||||
| Address2: | |||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920242478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604526334 | ||||||||
| FaxNumber: | 7603499755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 9400849 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 9400849 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | G161416 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 45580 | 01 | NC | BCBS | OTHER | P00612426 | 01 | NC | RAILROAD MEDICARE | OTHER | 1053353029 | 01 | CA | NPPES | OTHER | N00849 | 05 | SC | MEDICAID | 8945580 | 05 | NC | MEDICAID |