Healthcare Provider Details

I. General information

NPI: 1932432457
Provider Name (Legal Business Name): CAPITAL ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12499 UNIVERSITY AVE SUITE 210
CLIVE IA
50325-8281
US

IV. Provider business mailing address

12499 UNIVERSITY AVE SUITE 210
CLIVE IA
50325-8281
US

V. Phone/Fax

Practice location:
  • Phone: 515-440-2676
  • Fax: 515-440-2677
Mailing address:
  • Phone: 515-440-2676
  • Fax: 515-440-2677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number26239
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number19337
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number33389
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number27587
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number37744
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00693
License Number StateIA

VIII. Authorized Official

Name: DR. WILLIAM CHARLES JACOBSON
Title or Position: SHAREHOLDER
Credential: MD
Phone: 515-440-2676