Roland W. Jacobs, MD, PC
Organization Active NPI Psychiatry Physician · Valdez, NM
NPI 1861401705 · NPPES record last updated Feb 18, 2014
Key facts
- NPI
- 1861401705
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Psychiatry Physician 2084P0800X
- License
- 91225 (NM)
- Legal business name
- ROLAND W. JACOBS, MD, PC
- Practice address
- 156 Cerrito-Colorado Rd.
Valdez, NM 87580 - Phone
- (575) 770-7892
- Fax
- (575) 776-2922
- NPI assigned
- Aug 7, 2006
- Organization subpart
- No
Authorized official
- Name
- Dr. Roland W. Jacobs, M.D.
- Title
- President
- Phone
- (575) 770-7892
Practitioners 3
-
Roland W. Jacobs, M.D.
-
David Stuart Ullman, D.P.M.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in NM, CA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040728000243 | NM | Part B Supplier - Clinic/Group Practice | 3072583079 |
Receives reassigned benefits from 1 practitioner Practice locations: Taos, NM; Valdez, NM |
| O20041028000880 | CA | Part B Supplier - Clinic/Group Practice | 3072583079 |
Receives reassigned benefits from 1 practitioner Practice locations: Thousand Oaks, CA; Toluca Lake, CA; West Hills, CA; Woodland Hills, CA; Sherman Oaks, CA; Canoga Park, CA; Chatsworth, CA; Granada Hills, CA… |
National Provider Directory
Locations
413 Ocean Ave
Santa Monica, CA 90402
Phone (310) 393-0242
3680 N Moorpark Rd
Thousand Oaks, CA 91360
Phone (805) 496-9301
1399 Weimer Rd
Ste 200
Taos, NM 87571
Phone (505) 758-2224
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician |
2084P0800X | 91225 | NM | Yes |
Addresses
Primary practice location
156 Cerrito-Colorado Rd.
Valdez, NM 87580
Mailing address
PO Box 459
Arroyo Seco, NM 87514-0459
Phone (575) 770-7892
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 80077226 | Medicaid | NM | |
| W18090 | Other | CA | MEDICARE PTAN |
Other providers in Valdez, NM
All providers in Valdez, NM · Psychiatry Physician in New Mexico
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 18, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.