Provider Demographics
NPI:1376601443
Name:JACK, ROBERT LIONEL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LIONEL
Last Name:JACK
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 1:2452 WATSON CT
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-3216
Mailing Address - Country:US
Mailing Address - Phone:650-721-6888
Mailing Address - Fax:650-565-8297
Practice Address - Street 1:1225 CRANE ST
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4257
Practice Address - Country:US
Practice Address - Phone:650-323-0231
Practice Address - Fax:650-565-8297
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17236174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist