Healthcare Provider Details

I. General information

NPI: 1003252503
Provider Name (Legal Business Name): JACOB PODLESKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2013
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3011
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-326-6000
  • Fax:
Mailing address:
  • Phone: 417-347-1078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2017007787
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: