Provider Demographics
NPI:1346242690
Name:NUSSBAUM, JACK Z (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:Z
Last Name:NUSSBAUM
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 1:388 HAWKINS AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4280
Mailing Address - Country:US
Mailing Address - Phone:631-588-8460
Mailing Address - Fax:631-588-8480
Practice Address - Street 1:388 HAWKINS AVE
Practice Address - Street 2:STE 1
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4280
Practice Address - Country:US
Practice Address - Phone:631-588-8460
Practice Address - Fax:631-588-8480
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165161207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01824322Medicaid
NYE21328Medicare UPIN
NY17J021Medicare ID - Type Unspecified