Provider Demographics
NPI:1174818272
Name:THORUD, JAKOB CHRISTOPHER (DPM)
Entity Type:Individual
Prefix:
First Name:JAKOB
Middle Name:CHRISTOPHER
Last Name:THORUD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-3179
Mailing Address - Country:US
Mailing Address - Phone:815-578-2020
Mailing Address - Fax:815-344-3241
Practice Address - Street 1:3922 MERCY DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-3179
Practice Address - Country:US
Practice Address - Phone:815-578-2020
Practice Address - Fax:815-344-3241
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT28-2011213E00000X
IL016-005694213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1174818272Medicaid
WI1174818272OtherBCBSWI
WITHORUJAKOtherMERCYCARE INSURANCE
ILF400293923-214660Medicare PIN