Provider Demographics
NPI:1942491394
Name:JACOB, RYAN ANDRE (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ANDRE
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4228 HOUMA BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-3000
Mailing Address - Country:US
Mailing Address - Phone:504-264-9353
Mailing Address - Fax:504-301-9312
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-264-9353
Practice Address - Fax:504-301-9312
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD.201551208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2160613Medicaid