Healthcare Provider Details

I. General information

NPI: 1790034023
Provider Name (Legal Business Name): GARY PHILLIP JACOBS, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21500 PIONEER BLVD #210
HAWAIIAN GARDENS CA
90716-2600
US

IV. Provider business mailing address

21500 PIONEER BLVD #210
HAWAIIAN GARDENS CA
90716-2600
US

V. Phone/Fax

Practice location:
  • Phone: 562-360-1556
  • Fax: 562-786-8629
Mailing address:
  • Phone: 562-360-1556
  • Fax: 562-786-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA42016
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA42016
License Number StateCA

VIII. Authorized Official

Name: DR. GARY PHILLIP JACOBS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 562-360-1556