MEDICARE: DR. DAVID A JACOBY DOCTOR OF OPTOMETRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1171-3	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003811761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID A JACOBY DOCTOR OF OPTOMETRY

Provider Business Mailing Address
First Line	:	PO BOX 258
Second Line	:
City	:	OSAGE CITY
State	:	KS
Zip	:	66523-0258
Country	:	US
Telephone Number	:	785-528-4136
Fax Number	:	785-528-3422

Provider Business Practice Location Address
First Line	:	131 W MARKET ST STE A
Second Line	:
City	:	OSAGE CITY
State	:	KS
Zip	:	66523-1099
Country	:	US
Telephone Number	:	785-528-4136
Fax Number	:	785-528-3422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	02/23/2023

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