Healthcare Provider Details

I. General information

NPI: 1053060509
Provider Name (Legal Business Name): JACOB WESLEY SHULMISTER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 S BROADWAY
ENGLEWOOD CO
80113-4695
US

IV. Provider business mailing address

4055 S BROADWAY
ENGLEWOOD CO
80113-4695
US

V. Phone/Fax

Practice location:
  • Phone: 303-722-6864
  • Fax: 303-722-5113
Mailing address:
  • Phone: 303-722-6864
  • Fax: 303-722-5113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0000967
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number0000967
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: