Provider Demographics
NPI:1588676050
Name:JACOBS, JOHN YAGHOUBIEH (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:YAGHOUBIEH
Last Name:JACOBS
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:5657 WILSHIRE BLVD
Mailing Address - Street 2:130
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3736
Mailing Address - Country:US
Mailing Address - Phone:310-717-4901
Mailing Address - Fax:323-936-2731
Practice Address - Street 1:5657 WILSHIRE BLVD
Practice Address - Street 2:130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3736
Practice Address - Country:US
Practice Address - Phone:310-717-4901
Practice Address - Fax:323-936-2731
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOPT12983T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGV960ZMedicare PIN