Provider Demographics
NPI:1326089079
Name:WU, JACK C (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:WU
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 1:3845 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3505
Mailing Address - Country:US
Mailing Address - Phone:562-595-9206
Mailing Address - Fax:562-595-9209
Practice Address - Street 1:3845 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3505
Practice Address - Country:US
Practice Address - Phone:562-595-9206
Practice Address - Fax:562-595-9209
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A708800Medicaid
CAWA70880BMedicare ID - Type UnspecifiedMEDICARE PPIN
CA00A708800Medicaid
CAW20429Medicare ID - Type UnspecifiedMEDICARE GROUP ID
CAWA70880AMedicare ID - Type UnspecifiedMEDICARE ID NUMBER