Provider Demographics
NPI:1033109632
Name:OLDHAM, JACOB BLAINE
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:BLAINE
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 HIGHWAY 260 STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5851
Mailing Address - Country:US
Mailing Address - Phone:928-537-8777
Mailing Address - Fax:928-537-1914
Practice Address - Street 1:4830 HIGHWAY 260 STE 103
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5851
Practice Address - Country:US
Practice Address - Phone:928-537-8777
Practice Address - Fax:928-537-1914
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0490207X00000X
AZ41236207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery