Provider Demographics
NPI:1093719858
Name:JACOBS, IVAN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:RICHARD
Last Name:JACOBS
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 1:8501 WILSHIRE BLVD
Mailing Address - Street 2:STE 316
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3128
Mailing Address - Country:US
Mailing Address - Phone:310-652-2255
Mailing Address - Fax:310-652-2039
Practice Address - Street 1:8501 WILSHIRE BLVD
Practice Address - Street 2:STE 316
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3128
Practice Address - Country:US
Practice Address - Phone:310-652-2255
Practice Address - Fax:310-652-2039
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-09-25
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
CAC27493207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C274930OtherBLUE SHIELD
CA00C274930Medicaid
CAWC27493AMedicare PIN
CA00C274930OtherBLUE SHIELD