=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417051079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB SALEH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18370 BURBANK BLVD SUITE 714
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-996-6100
-----------------------------------------------------
Fax | 818-668-8323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 260994
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91426-0994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-996-6100
-----------------------------------------------------
Fax | 818-668-8323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | A40910
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------