Provider Demographics
NPI:1083904080
Name:FANG, JACK JIENAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:JIENAN
Last Name:FANG
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 1:4323 COLDEN ST APT 19M
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5926
Mailing Address - Country:US
Mailing Address - Phone:347-205-7909
Mailing Address - Fax:
Practice Address - Street 1:6265 SAUNDERS ST APT 5G
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1576
Practice Address - Country:US
Practice Address - Phone:347-205-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA260808207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine