Provider Demographics
NPI:1720263924
Name:CHODAKIEWITZ, JACOBO W (MD)
Entity type:Individual
Prefix:
First Name:JACOBO
Middle Name:W
Last Name:CHODAKIEWITZ
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 1:1125 S BEVERLY DR
Mailing Address - Street 2:STE.610
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1148
Mailing Address - Country:US
Mailing Address - Phone:310-553-3379
Mailing Address - Fax:
Practice Address - Street 1:1125 S BEVERLY DR
Practice Address - Street 2:STE.610
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1148
Practice Address - Country:US
Practice Address - Phone:310-553-3379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA038243174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38243Medicare UPIN