Provider Demographics
NPI:1396843777
Name:JACK C. WU, M.D. P.A.
Entity Type:Organization
Organization Name:JACK C. WU, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-456-1881
Mailing Address - Street 1:219 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08093-1014
Mailing Address - Country:US
Mailing Address - Phone:856-456-1881
Mailing Address - Fax:856-456-3959
Practice Address - Street 1:219 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08093-1014
Practice Address - Country:US
Practice Address - Phone:856-456-1881
Practice Address - Fax:856-456-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07468500207Q00000X
NJ25MA298330305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC54210Medicare UPIN