Provider Demographics
NPI:1154601805
Name:JACOBELLI, DOMINIC AMADEO (MD)
Entity type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:AMADEO
Last Name:JACOBELLI
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 1:1000 S 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8610
Mailing Address - Country:US
Mailing Address - Phone:479-271-9607
Mailing Address - Fax:
Practice Address - Street 1:1000 S 52ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-271-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11530207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine