Provider Demographics
NPI:1407880032
Name:KAZANJIAN, JACK ELIAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ELIAS
Last Name:KAZANJIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4630
Mailing Address - Country:US
Mailing Address - Phone:610-449-6499
Mailing Address - Fax:610-449-9814
Practice Address - Street 1:510 DARBY RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4630
Practice Address - Country:US
Practice Address - Phone:610-449-6499
Practice Address - Fax:610-449-9814
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010372L207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018681980001Medicaid
H95648Medicare UPIN
PA1018681980001Medicaid