Provider Demographics
NPI:1225008030
Name:KATZ, JACK L (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:KATZ
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 1:104 ELIZABETH RD
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-3107
Mailing Address - Country:US
Mailing Address - Phone:914-235-8191
Mailing Address - Fax:
Practice Address - Street 1:1010 NORTHERN BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5306
Practice Address - Country:US
Practice Address - Phone:516-336-2565
Practice Address - Fax:516-336-2564
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0868722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC09965Medicare UPIN
NY442441Medicare ID - Type Unspecified