Provider Demographics
NPI:1376527481
Name:SACK, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:ALAN
Last Name:SACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20533 BISCAYNE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1529
Mailing Address - Country:US
Mailing Address - Phone:954-450-7172
Mailing Address - Fax:954-450-0222
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 208
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-450-7172
Practice Address - Fax:954-450-0222
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0059745207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02010891OtherMEDICAID NY
FL372999100Medicaid
NY02010891OtherMEDICAID NY
FL372999100Medicaid