Provider Demographics
NPI:1114119542
Name:JACOB, SHUSHAN (MD)
Entity type:Individual
Prefix:DR
First Name:SHUSHAN
Middle Name:
Last Name:JACOB
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 E SOUTHLAKE BLVD STE L-605
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6516
Mailing Address - Country:US
Mailing Address - Phone:267-408-9036
Mailing Address - Fax:
Practice Address - Street 1:6900 N PECOS RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7548208600000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286943004Medicaid
TX286943005Medicaid
TXTXB163384Medicare PIN
TX286943004Medicaid
TXTXB163377Medicare PIN