Healthcare Provider Details

I. General information

NPI: 1831514686
Provider Name (Legal Business Name): JACOB DUBAY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 CONNECTICUT AVE S
SARTELL MN
56377
US

IV. Provider business mailing address

8170 33RD AVE S MAIL STOP 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5220
  • Fax: 320-203-2200
Mailing address:
  • Phone: 320-253-5220
  • Fax: 320-203-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number66318
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: