Provider Demographics
NPI:1326224783
Name:TOMSIC, JACLYN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:A
Last Name:TOMSIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 PARK EAST DR APT 539
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4358
Mailing Address - Country:US
Mailing Address - Phone:440-213-9459
Mailing Address - Fax:
Practice Address - Street 1:6701 ROCKSIDE RD STE 209
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2316
Practice Address - Country:US
Practice Address - Phone:216-328-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0226961223G0001X
OH30.0226961223S0112X
MO20140255841223S0112X
MO2014032411208600000X
OH35.136163204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery