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General NPI Number Information
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NPI Number | 1316205644
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Entity Type | Organization
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Legal Business Name | J. BRUCE JACOBS, M.D., INC.
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Dates
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Enumeration Date | 04/24/2012
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Last Update Date | 01/27/2014
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Provider Practice Location Address
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Address Line | 1821 W OLIVE AVE
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City | BURBANK
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State | CA
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Zip | 91506-2435
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Country | US
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Telephone | 818-841-8880
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Fax | 818-841-8884
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Provider Business Mailing Address
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Address Line | 1821 W OLIVE AVE
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City | BURBANK
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State | CA
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Zip | 91506-2435
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Country | US
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Telephone | 818-841-8880
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Fax | 818-841-8884
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALEXANDER USMANOV
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Credential | M.D.
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Telephone | 818-841-8880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | A21604
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License Number State | CA
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