Provider Demographics
NPI:1215230297
Name:J. BRUCE JACOBS, MD, INC
Entity Type:Organization
Organization Name:J. BRUCE JACOBS, MD, INC
Other - Org Name:DOWNEY RADIOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:USMANOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-904-1111
Mailing Address - Street 1:11525 BROOKSHIRE AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4985
Mailing Address - Country:US
Mailing Address - Phone:562-904-1111
Mailing Address - Fax:562-861-6666
Practice Address - Street 1:11525 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4985
Practice Address - Country:US
Practice Address - Phone:562-904-1111
Practice Address - Fax:562-861-6666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA216042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215230297Medicaid
CA1215230297Medicaid