Provider Demographics
NPI:1831486810
Name:DEISTER, JACOB C (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:C
Last Name:DEISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:C
Other - Last Name:DEISTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2660 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-2442
Mailing Address - Country:US
Mailing Address - Phone:785-270-8880
Mailing Address - Fax:
Practice Address - Street 1:2660 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-2442
Practice Address - Country:US
Practice Address - Phone:785-270-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39039207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002387OtherMEDICARE PTAN
KS201136410AMedicaid