Provider Demographics
NPI:1407842214
Name:POMERANTZ, JACK M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:POMERANTZ
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:DEPT AT952639
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31192-2639
Mailing Address - Country:US
Mailing Address - Phone:800-684-0857
Mailing Address - Fax:405-844-1794
Practice Address - Street 1:3200 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4615
Practice Address - Country:US
Practice Address - Phone:907-202-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020657207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1903728Medicaid
LA1903728Medicaid
LA5N338CQ60Medicare PIN
LAE65829Medicare UPIN