Provider Demographics
NPI:1043386287
Name:DAVID A JACOBY OD CHARTERED
Entity type:Organization
Organization Name:DAVID A JACOBY OD CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-803-8616
Mailing Address - Street 1:131 W MARKET ST STE A
Mailing Address - Street 2:
Mailing Address - City:OSAGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66523-1099
Mailing Address - Country:US
Mailing Address - Phone:620-803-8616
Mailing Address - Fax:
Practice Address - Street 1:131 W MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:OSAGE CITY
Practice Address - State:KS
Practice Address - Zip Code:66523
Practice Address - Country:US
Practice Address - Phone:785-528-4136
Practice Address - Fax:785-528-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1171-3332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004700180001Medicaid
KS0349420001Medicare NSC