Provider Demographics
NPI:1669545240
Name:JACOBS, PARVIN MODABER (MD)
Entity type:Individual
Prefix:
First Name:PARVIN
Middle Name:MODABER
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2870 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-5031
Mailing Address - Country:US
Mailing Address - Phone:702-735-0258
Mailing Address - Fax:702-735-9140
Practice Address - Street 1:2870 S MARYLAND PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-5031
Practice Address - Country:US
Practice Address - Phone:702-735-0258
Practice Address - Fax:702-735-9140
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2083207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002224Medicaid
NVNV2083OtherBCROSS-BSHIELD PROV#
NVC96543Medicare UPIN
NV11WCHFG05Medicare ID - Type UnspecifiedMEDICARE PROVIDER#