MEDICARE: DR. JACOB BLAINE OLDHAM

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	207X00000X	Orthopaedic Surgery Physician	MD2005-0490	NM
2	207X00000X	Orthopaedic Surgery Physician	41236	AZ

General Provider Information

NPI Number	:	1033109632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB BLAINE OLDHAM

Provider Business Mailing Address
First Line	:	4830 HIGHWAY 260 STE 103
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5851
Country	:	US
Telephone Number	:	928-537-8777
Fax Number	:	928-537-1914

Provider Business Practice Location Address
First Line	:	4830 HIGHWAY 260 STE 103
Second Line	:
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5851
Country	:	US
Telephone Number	:	928-537-8777
Fax Number	:	928-537-1914

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

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	10/20/2022

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