Provider Demographics
NPI:1417944661
Name:FRIEDLAND, JACK A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:FRIEDLAND
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 1:5233 E ARROYO RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-3321
Mailing Address - Country:US
Mailing Address - Phone:602-617-0000
Mailing Address - Fax:602-952-1001
Practice Address - Street 1:5410 N SCOTTSDALE ROAD
Practice Address - Street 2:SUITE E200
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-5945
Practice Address - Country:US
Practice Address - Phone:480-905-1700
Practice Address - Fax:480-505-6429
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5939208200000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ201252Medicaid
AZAZ0779280OtherBC OF ARIZONA ID NUMBER
AZ201252Medicaid
AZD36869Medicare UPIN