Provider Demographics
NPI:1093792053
Name:BELEN, JACK E (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:BELEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1862
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:28080 GRAND RIVER AVE STE 306N
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:947-521-8968
Practice Address - Fax:248-471-8061
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101006431207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21770011Medicaid
A73658Medicare UPIN
MI21770011Medicaid