Provider Demographics
NPI:1689735664
Name:JACOBS, ROBERT KENAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENAN
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 1:1201 E SCHUSTER AVE
Mailing Address - Street 2:BUILDING 3A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4646
Mailing Address - Country:US
Mailing Address - Phone:915-533-1630
Mailing Address - Fax:915-533-4116
Practice Address - Street 1:1201 E SCHUSTER AVE
Practice Address - Street 2:BUILDING 3A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4646
Practice Address - Country:US
Practice Address - Phone:915-533-1630
Practice Address - Fax:915-533-4116
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1069208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C17365Medicare UPIN
000HL45Medicare ID - Type Unspecified