Provider Demographics
NPI:1134160609
Name:FAKOORY, JACOB JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHN
Last Name:FAKOORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1227 ARNO DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024-1568
Mailing Address - Country:US
Mailing Address - Phone:626-355-8121
Mailing Address - Fax:626-355-8987
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-2344
Practice Address - Fax:818-502-4501
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC39375207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C393750Medicaid
CAA89077Medicare UPIN
CA00C393750Medicaid
CAWC39375Medicare ID - Type Unspecified
CAWC39375IMedicare PIN