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General NPI Number Information
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NPI Number | 1588967566
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Entity Type | Organization
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Legal Business Name | J. BRUCE JACOBS, MD, INC
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Dates
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Enumeration Date | 12/13/2010
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Last Update Date | 01/28/2014
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Provider Practice Location Address
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Address Line | 17779 VENTURA BLVD
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City | ENCINO
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State | CA
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Zip | 91316-3717
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Country | US
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Telephone | 818-776-9100
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Fax | 818-776-0544
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Provider Business Mailing Address
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Address Line | 17779 VENTURA BLVD
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City | ENCINO
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State | CA
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Zip | 91316-3717
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Country | US
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Telephone | 818-776-9100
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Fax | 818-776-0544
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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 | 818-776-9100
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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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