Provider Demographics
NPI:1790749448
Name:JACOBSON, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12499 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8281
Mailing Address - Country:US
Mailing Address - Phone:515-440-2676
Mailing Address - Fax:515-440-2677
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50325-8281
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:515-440-2677
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33389207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA200044900OtherRAILROAD MEDICARE
43972OtherBLUE CROSS BLUE SHIELD
IA2205187Medicaid
G97473Medicare UPIN
43972OtherBLUE CROSS BLUE SHIELD
IAI11077Medicare PIN