Provider Demographics
NPI:1447457171
Name:JACOBS, RICHARD R (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 ADMIRAL CT
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8055
Mailing Address - Country:US
Mailing Address - Phone:702-582-7540
Mailing Address - Fax:
Practice Address - Street 1:2801 CLEARWATER CT
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-8239
Practice Address - Country:US
Practice Address - Phone:732-233-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361177692085R0001X
IN01067878A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201014850Medicaid
NJ2SMA06320300OtherSTATE LICENSE
IN000000705885OtherANTHEM PROVIDER NUMBER
KS0432464OtherSTATE LICENSE
INM400042002Medicare PIN
KS0432464OtherSTATE LICENSE
IN201014850Medicaid