Provider Demographics
NPI:1730294893
Name:JACOB, RODNEY LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:LEIGH
Last Name:JACOB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 451
Mailing Address - Street 2:
Mailing Address - City:TSAILE
Mailing Address - State:AZ
Mailing Address - Zip Code:86556-0451
Mailing Address - Country:US
Mailing Address - Phone:928-724-3162
Mailing Address - Fax:928-724-3781
Practice Address - Street 1:INDIAN ROUTE 64 AND 12
Practice Address - Street 2:TSAILE HEALTH CLINIC
Practice Address - City:TSAILE
Practice Address - State:AZ
Practice Address - Zip Code:85665-0021
Practice Address - Country:US
Practice Address - Phone:928-724-3707
Practice Address - Fax:928-724-3781
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2548152W00000X
MS816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO91064Medicare ID - Type Unspecified
MOU76140Medicare UPIN
MO07288OtherSPECTERA