Healthcare Provider Details

I. General information

NPI: 1033109632
Provider Name (Legal Business Name): DR. JACOB BLAINE OLDHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

IV. Provider business mailing address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-6700
  • Fax: 928-532-2138
Mailing address:
  • Phone: 928-537-6700
  • Fax: 928-532-2138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number41236
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2005-0490
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: