Provider Demographics
NPI:1295726172
Name:JACOBUS, DWAYNE AUBREY (DPM)
Entity type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:AUBREY
Last Name:JACOBUS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 LAURELHURST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3825
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-753-5591
Practice Address - Street 1:3800 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6446
Practice Address - Country:US
Practice Address - Phone:803-705-3172
Practice Address - Fax:803-705-3173
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC565213E00000X, 213ES0131X, 213EP1101X
TN847213E00000X, 213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT14910AOtherMEDICARE TN
SCPD5658Medicaid
TNQ058390Medicaid
TNQ058390Medicaid