Provider Demographics
NPI:1225015233
Name:JACOB OFFENBERGER MD INC
Entity type:Organization
Organization Name:JACOB OFFENBERGER MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:OFFENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-366-8112
Mailing Address - Street 1:10515 BALBOA BLVD
Mailing Address - Street 2:STE 390
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344
Mailing Address - Country:US
Mailing Address - Phone:818-366-8112
Mailing Address - Fax:818-366-6002
Practice Address - Street 1:10515 BALBOA BLVD
Practice Address - Street 2:STE 390
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344
Practice Address - Country:US
Practice Address - Phone:818-366-8112
Practice Address - Fax:818-366-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38800207K00000X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Not Answered2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C55513Medicare UPIN
CAA38808Medicare ID - Type Unspecified