Basic Information
| Provider Information | |||||||||
| NPI: | 1093759151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | DUDLEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 WEST STETSON AVENUE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515376002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 809 WEST STETSON AVENUE SUITE B | ||||||||
| Address2: | APEX RADIOLOGY MEDICAL GROUP, INC | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515376002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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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 | 2085R0202X | G63250 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G632502 | 01 | CA | MEDICARE PTAN | OTHER | 300116435 | 01 | CA | RAILROAD | OTHER | 00G632501 | 01 | CA | MEDICARE PTAN | OTHER | 300116419 | 01 | CA | RAILROAD | OTHER | 300116433 | 01 | CA | RAILROAD | OTHER | 00G632500 | 05 | CA | MEDICAID |