Provider Demographics
NPI:1184664088
Name:SOBEL, JACK DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DAVID
Last Name:SOBEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-4525
Mailing Address - Fax:313-577-3223
Practice Address - Street 1:3750 WOODWARD
Practice Address - Street 2:STE 200
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2007
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-993-4663
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-11-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301049010207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630124Medicare PIN