Provider Demographics
NPI:1861569675
Name:ISHKANIAN, JACOB M (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:ISHKANIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HAGOP
Other - Middle Name:M
Other - Last Name:ISHKHANIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25825 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3518
Mailing Address - Country:US
Mailing Address - Phone:310-325-5111
Mailing Address - Fax:310-517-4177
Practice Address - Street 1:25825 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:310-325-5111
Practice Address - Fax:310-517-4177
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39035204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM