Basic Information
| Provider Information | |||||||||
| NPI: | 1609819770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSTEIN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015524 | ||||||||
| FaxNumber: | 4106018946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2411 W BELVEDERE AVE STE 407 | ||||||||
| Address2: | MORTON MOWER, M.D., MOB | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106018663 | ||||||||
| FaxNumber: | 4106015389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/03/2010 | ||||||||
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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 | 2080P0206X | D006268 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 408097100 | 05 | MD | MEDICAID |