Provider Demographics
NPI:1164476628
Name:MCANINCH, JACK WELDON (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WELDON
Last Name:MCANINCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7464
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94120-7464
Mailing Address - Country:US
Mailing Address - Phone:415-206-3103
Mailing Address - Fax:415-206-3872
Practice Address - Street 1:1001 POTRERO AVENUE
Practice Address - Street 2:RM 3A20
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-8806
Practice Address - Fax:415-206-5153
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG14761208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G147610Medicaid
CA00G147610Medicaid
CA00G147610Medicare ID - Type Unspecified