Provider Demographics
NPI:1205222858
Name:KAHANE, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KAHANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 BIG HORN RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1900
Mailing Address - Country:US
Mailing Address - Phone:413-539-3500
Mailing Address - Fax:
Practice Address - Street 1:3001 BROADMOOR BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2100
Practice Address - Country:US
Practice Address - Phone:505-994-7397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2022-0238207YX0901X
LA322577207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology