=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588676050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN YAGHOUBIEH JACOBS O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 07/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5657 WILSHIRE BLVD 130
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-717-4901
-----------------------------------------------------
Fax | 323-936-2731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5657 WILSHIRE BLVD 130
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-717-4901
-----------------------------------------------------
Fax | 323-936-2731
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT12983T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------