Provider Demographics
NPI:1114114881
Name:JACK J DRUET, MD, INC.
Entity Type:Organization
Organization Name:JACK J DRUET, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DRUET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-506-9536
Mailing Address - Street 1:43500 RIDGE PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3624
Mailing Address - Country:US
Mailing Address - Phone:951-699-0303
Mailing Address - Fax:951-699-1145
Practice Address - Street 1:25495 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5963
Practice Address - Country:US
Practice Address - Phone:951-506-9536
Practice Address - Fax:951-693-4631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70999207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC4371OtherRAILROAD MEDICARE GRP.
CABD4190889OtherDEA
CAF81979Medicare UPIN
CAZZZ30228ZMedicare PIN