Provider Demographics
NPI:1659439040
Name:JACOBS, SHAHRAM (MD)
Entity Type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHAHRAM
Other - Middle Name:
Other - Last Name:POURRABBANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:16133 VENTURA BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2403
Mailing Address - Country:US
Mailing Address - Phone:310-500-8688
Mailing Address - Fax:818-986-2415
Practice Address - Street 1:16133 VENTURA BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2403
Practice Address - Country:US
Practice Address - Phone:310-500-8688
Practice Address - Fax:818-986-2415
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI49167Medicare UPIN
CAWA89999DMedicare PIN