Healthcare Provider Details

I. General information

NPI: 1528467693
Provider Name (Legal Business Name): JACOB B. REDEKOP MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 N CAMINO ESCUELA
TUCSON AZ
85718-5016
US

IV. Provider business mailing address

5201 N CAMINO ESCUELA
TUCSON AZ
85718-5016
US

V. Phone/Fax

Practice location:
  • Phone: 520-299-2248
  • Fax: 520-299-2248
Mailing address:
  • Phone: 520-299-2248
  • Fax: 520-299-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4770
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number4770
License Number StateAZ

VIII. Authorized Official

Name: DR. JACOB B. REDEKOP
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 520-299-2248