Provider Demographics
NPI:1366630808
Name:JACK L CASSELL M.D. P.A.
Entity Type:Organization
Organization Name:JACK L CASSELL M.D. P.A.
Other - Org Name:UROLOGY OF MOUNT DORA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-383-3773
Mailing Address - Street 1:717 N DONNELLY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-4833
Mailing Address - Country:US
Mailing Address - Phone:352-383-3773
Mailing Address - Fax:352-383-4434
Practice Address - Street 1:717 N DONNELLY ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-4833
Practice Address - Country:US
Practice Address - Phone:352-383-3773
Practice Address - Fax:352-383-4434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACK L CASSELL M.D. P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-10
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46095174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254899200Medicaid
FL254899200Medicaid