Provider Demographics
NPI:1346325180
Name:SHOHET, JACK A (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:SHOHET
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 1:446 OLD NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4246
Mailing Address - Country:US
Mailing Address - Phone:949-631-4327
Mailing Address - Fax:949-631-2030
Practice Address - Street 1:446 OLD NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4246
Practice Address - Country:US
Practice Address - Phone:949-631-0409
Practice Address - Fax:949-631-2030
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54420207YX0901X
CAG83612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty