Provider Demographics
NPI:1033180724
Name:DWOSH, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:DWOSH
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 1:15000 MIDLANTIC DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1573
Mailing Address - Country:US
Mailing Address - Phone:856-252-1000
Mailing Address - Fax:856-252-1100
Practice Address - Street 1:15000 MIDLANTIC DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MT. LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054
Practice Address - Country:US
Practice Address - Phone:856-252-1000
Practice Address - Fax:856-252-1100
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064953L208800000X
NJ25MA04771800208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0055472OtherAETNA
0073781000OtherAMERIHEALTH
C58105Medicare UPIN
0055472OtherAETNA