Provider Demographics
NPI:1013013242
Name:FAUP, JACK G (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:G
Last Name:FAUP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1515 PARK CENTER DR
Mailing Address - Street 2:SUITE 2 I
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5794
Mailing Address - Country:US
Mailing Address - Phone:407-299-3160
Mailing Address - Fax:407-299-2445
Practice Address - Street 1:1515 PARK CENTER DR
Practice Address - Street 2:SUITE 2 I
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5794
Practice Address - Country:US
Practice Address - Phone:407-299-3160
Practice Address - Fax:407-299-2445
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME15851207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048731700Medicaid
FLD64211Medicare UPIN
FL48641ZMedicare PIN