Provider Demographics
NPI:1336140938
Name:SALAH, JACK JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:JERRY
Last Name:SALAH
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 1:8236 SHADY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7361
Mailing Address - Country:US
Mailing Address - Phone:904-645-9655
Mailing Address - Fax:
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 901
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-398-6971
Practice Address - Fax:904-398-2497
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041346207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045079100Medicaid
FL77530Medicare ID - Type UnspecifiedMEDICARE
FL045079100Medicaid