Provider Demographics
NPI:1538328489
Name:THOMAS, JACOB K (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:K
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1265 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4278
Mailing Address - Country:US
Mailing Address - Phone:417-886-3937
Mailing Address - Fax:417-886-1285
Practice Address - Street 1:1265 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4278
Practice Address - Country:US
Practice Address - Phone:417-886-3937
Practice Address - Fax:417-886-1285
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXN1182207W00000X
MO2012003514207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407856263Medicaid