Healthcare Provider Details

I. General information

NPI: 1063723781
Provider Name (Legal Business Name): JACOB O WARDWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SUTTER ST RM 1341
SAN FRANCISCO CA
94108-4007
US

IV. Provider business mailing address

450 SUTTER ST RM 1341
SAN FRANCISCO CA
94108-4007
US

V. Phone/Fax

Practice location:
  • Phone: 415-606-0309
  • Fax: 415-862-0626
Mailing address:
  • Phone: 415-606-0309
  • Fax: 415-862-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number12776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: