Provider Demographics
NPI:1114119542
Name:JACOB, SHUSHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHUSHAN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 E SOUTHLAKE BLVD STE L-605
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6516
Mailing Address - Country:US
Mailing Address - Phone:817-404-4811
Mailing Address - Fax:833-974-2284
Practice Address - Street 1:1668 KELLER PKWY STE 300
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3710
Practice Address - Country:US
Practice Address - Phone:817-404-4811
Practice Address - Fax:833-974-2284
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7548208600000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286943004Medicaid
TX286943005Medicaid
TXTXB163384Medicare PIN
TX286943004Medicaid
TXTXB163377Medicare PIN