Provider Demographics
NPI:1427188879
Name:JEDWAB, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:JEDWAB
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 1:2270 KIMBALL ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5139
Mailing Address - Country:US
Mailing Address - Phone:718-377-7575
Mailing Address - Fax:718-377-8566
Practice Address - Street 1:2270 KIMBALL ST
Practice Address - Street 2:SUITE 214
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5139
Practice Address - Country:US
Practice Address - Phone:718-377-7575
Practice Address - Fax:718-377-8566
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1399762088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00495565Medicaid
27A801Medicare ID - Type Unspecified
NY00495565Medicaid