Healthcare Provider Details

I. General information

NPI: 1932631454
Provider Name (Legal Business Name): JACOB KOLKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 DUFF AVE
AMES IA
50010-5469
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-5469
US

V. Phone/Fax

Practice location:
  • Phone: 515-239-4404
  • Fax:
Mailing address:
  • Phone: 515-239-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49535
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: