Provider Demographics
NPI:1023230638
Name:JACOB K AHDOOT MD INC
Entity type:Organization
Organization Name:JACOB K AHDOOT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:K
Authorized Official - Last Name:AHDOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-753-8882
Mailing Address - Street 1:15775 LAGUNA CANYON RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3145
Mailing Address - Country:US
Mailing Address - Phone:949-753-8882
Mailing Address - Fax:949-727-3793
Practice Address - Street 1:15775 LAGUNA CANYON RD
Practice Address - Street 2:SUITE 220
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3145
Practice Address - Country:US
Practice Address - Phone:949-753-8882
Practice Address - Fax:949-727-3793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46389207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00070549OtherMEDICARE RAILROAD PROVIDER#
CAF60273Medicare UPIN
CAW19251Medicare PIN