Provider Demographics
NPI:1215373147
Name:DEMASTER, JACOB TAIT (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:TAIT
Last Name:DEMASTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6125
Mailing Address - Country:US
Mailing Address - Phone:920-458-4010
Mailing Address - Fax:
Practice Address - Street 1:1813 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6125
Practice Address - Country:US
Practice Address - Phone:920-458-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-19
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100058168Medicaid