Provider Demographics
NPI:1326029802
Name:JAC, JAROSLAW (MD)
Entity Type:Individual
Prefix:
First Name:JAROSLAW
Middle Name:
Last Name:JAC
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 1:15 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1011
Mailing Address - Country:US
Mailing Address - Phone:207-351-2478
Mailing Address - Fax:207-351-2216
Practice Address - Street 1:150 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1017
Practice Address - Country:US
Practice Address - Phone:508-870-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA238060207R00000X, 207RH0003X
TXJ9106207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110081560/AMedicaid
TX139379518Medicaid
8D7918Medicare ID - Type Unspecified
MA110081560/AMedicaid
TX8G2207Medicare PIN
TX139379518Medicaid