Provider Demographics
NPI:1467464255
Name:NASS, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:NASS
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 1:580 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6003
Mailing Address - Country:US
Mailing Address - Phone:631-321-7697
Mailing Address - Fax:631-321-6140
Practice Address - Street 1:580 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6003
Practice Address - Country:US
Practice Address - Phone:631-321-7697
Practice Address - Fax:631-321-6140
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1286972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00381388Medicaid
NY00381388Medicaid