MEDICARE: J. BRUCE JACOBS, MD, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	A21604	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316240393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. BRUCE JACOBS, MD, INC

Provider Business Mailing Address
First Line	:	3055 WILSHIRE BLVD
Second Line	:	SUITE150
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-1108
Country	:	US
Telephone Number	:	213-487-4077
Fax Number	:	213-487-7517

Provider Business Practice Location Address
First Line	:	3055 WILSHIRE BLVD
Second Line	:	SUITE150
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-1108
Country	:	US
Telephone Number	:	213-487-4077
Fax Number	:	213-487-7517

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALEXANDER USMANOV
Credential	:	M.D.
Telephone Number	:	213-487-4077

Provider Enumeration Date	:	12/13/2010
Last Update Date	:	01/28/2014

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