Basic Information
| Provider Information | |||||||||
| NPI: | 1710964044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2560 N. SHADELAND AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172758072 | ||||||||
| FaxNumber: | 3172758018 | ||||||||
| Practice Location | |||||||||
| Address1: | 2560 N. SHADELAND AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462191706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172758072 | ||||||||
| FaxNumber: | 3172758018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207ZP0102X | 01025252A | IN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000344920 | 01 | IN | ANTHEM | OTHER |