Healthcare Provider Details

I. General information

NPI: 1629044458
Provider Name (Legal Business Name): TAD JACOBS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 10TH ST
DELL RAPIDS SD
57022-1217
US

IV. Provider business mailing address

111 E 10TH ST
DELL RAPIDS SD
57022-1217
US

V. Phone/Fax

Practice location:
  • Phone: 605-997-2471
  • Fax: 605-997-2418
Mailing address:
  • Phone: 605-428-5446
  • Fax: 605-428-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1258
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: