Basic Information
| Provider Information | |||||||||
| NPI: | 1679598262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | LEONARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5535 FAIR LN | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452273434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132215274 | ||||||||
| FaxNumber: | 5139615100 | ||||||||
| Practice Location | |||||||||
| Address1: | 5240 E GALBRAITH RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452362877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137459787 | ||||||||
| FaxNumber: | 5137459789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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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 | 207W00000X | 35030761 | OH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0133993 | 05 | OH | MEDICAID |