Doctor Name: | JACOB O WARDWELL |
NPI Number: | 1063723781 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DO |
License Number: | OS11640 |
Business Practice Address: | 246 1st Street #101 San Francisco, CA - 94105 |
Business Phone Number: | 4154952225 |
Business Fax Number: | 4154952228 |
Mailing Address: | P.o. Box 1848, NOVATO |
State: | CA |
Postal Code: | 94948 |
Phone Number: | 4158927560 |
Fax Number: | 4158927509 |
NPI Enumeration Date: | 06/28/2010 |
NPI Last Update Date: | 04/03/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | OS11640 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |