Basic Information
| Provider Information | |||||||||
| NPI: | 1699794206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAMB | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5139 MATTIS RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149091920 | ||||||||
| FaxNumber: | 3149091980 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 COLLEGE AVE STE B | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629695 | ||||||||
| FaxNumber: | 6184629651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005235 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 2004017476 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016005235 | 05 | IL | MEDICAID | 301122503 | 05 | MO | MEDICAID |