Provider Demographics
NPI:1093724239
Name:TOM, JACK PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:PHILIP
Last Name:TOM
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 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:631-444-0004
Mailing Address - Fax:631-444-0088
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 211
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-444-0004
Practice Address - Fax:631-444-0088
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155342207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01711760Medicaid
NY01711760Medicaid
NYA63692Medicare UPIN