Provider Demographics
NPI:1376542217
Name:MANN, JACK MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MICHAEL
Last Name:MANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:42-23 FRANCIS LEWIS BLVD.
Mailing Address - Street 2:STE. 105
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361
Mailing Address - Country:US
Mailing Address - Phone:718-225-5106
Mailing Address - Fax:718-225-0816
Practice Address - Street 1:42-23 FRANCIS LEWIS BLVD.
Practice Address - Street 2:STE. 105
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361
Practice Address - Country:US
Practice Address - Phone:718-225-5106
Practice Address - Fax:718-225-0816
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY158742207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00923579Medicaid
NYA63736Medicare UPIN
NY41C042Medicare ID - Type Unspecified