Provider Demographics
NPI:1245456417
Name:JACOB, DESIDERIO C (MD)
Entity type:Individual
Prefix:DR
First Name:DESIDERIO
Middle Name:C
Last Name:JACOB
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 1:960 PASEO LA CRESTA
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-2053
Mailing Address - Country:US
Mailing Address - Phone:310-373-3868
Mailing Address - Fax:310-631-6425
Practice Address - Street 1:2140 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-5311
Practice Address - Country:US
Practice Address - Phone:310-631-1107
Practice Address - Fax:310-631-6425
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23679305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23679OtherCA MEDICAL LICENSE
CAA82844Medicare UPIN