Provider Demographics
NPI:1164505483
Name:CASSELL, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:CASSELL
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 1:717 NORTH DONNELLY STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757
Mailing Address - Country:US
Mailing Address - Phone:352-383-3773
Mailing Address - Fax:352-383-4434
Practice Address - Street 1:717 NORTH DONNELLY STREET
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757
Practice Address - Country:US
Practice Address - Phone:352-383-3773
Practice Address - Fax:352-383-4434
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46095208600000X, 2086X0206X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
6515446002OtherCIGNA
04857OtherBCBS FL
FL254899200Medicaid
340013414OtherRR MEDICARE
FL053421800Medicaid
FL053421800Medicaid
04857OtherBCBS FL
340013414OtherRR MEDICARE