Provider Demographics
NPI:1366462939
Name:JACOBS, EDWIN LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:LAWRENCE
Last Name:JACOBS
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:PO BOX 51194
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5494
Mailing Address - Country:US
Mailing Address - Phone:818-840-0921
Mailing Address - Fax:818-840-7064
Practice Address - Street 1:181 S BUENA VISTA ST
Practice Address - Street 2:4RTH FLOOR
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4504
Practice Address - Country:US
Practice Address - Phone:818-840-0921
Practice Address - Fax:818-840-7064
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62813207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG628130Medicaid
CAOOG628130Medicaid
CAE88792Medicare UPIN
CAWG62813AMedicare ID - Type Unspecified