Healthcare Provider Details

I. General information

NPI: 1205222858
Provider Name (Legal Business Name): JACOB KAHANE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number322577
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberMD2022-0238
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: