Healthcare Provider Details

I. General information

NPI: 1326366279
Provider Name (Legal Business Name): JACOB SEDGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2010
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 SUNSET BLVD SUITE #M130
LOS ANGELES CA
90069
US

IV. Provider business mailing address

9201 SUNSET BLVD SUITE #M130
LOS ANGELES CA
90069
US

V. Phone/Fax

Practice location:
  • Phone: 310-888-2884
  • Fax: 310-276-6801
Mailing address:
  • Phone: 310-888-2884
  • Fax: 310-276-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberA117462
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA117462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: