MEDICARE: DR. DWAYNE AUBREY JACOBUS D.P.M.

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	213E00000X	Podiatrist	565	SC
2	213E00000X	Podiatrist	847	TN
3	213EP1101X	Primary Podiatric Medicine Podiatrist	847	TN
4	213ES0131X	Foot Surgery Podiatrist	847	TN
5	213ES0131X	Foot Surgery Podiatrist	565	SC
6	213EP1101X	Primary Podiatric Medicine Podiatrist	565	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	T14910A	OTHER	TN	MEDICARE TN

Other Identifiers

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

General Provider Information

NPI Number	:	1295726172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWAYNE AUBREY JACOBUS D.P.M.

Provider Business Mailing Address
First Line	:	169 LAURELHURST AVE
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29210-3825
Country	:	US
Telephone Number	:	803-733-5969
Fax Number	:	803-753-5591

Provider Business Practice Location Address
First Line	:	3800 N MAIN ST STE B
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6446
Country	:	US
Telephone Number	:	803-705-3172
Fax Number	:	803-705-3173

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	03/07/2023

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