Provider Demographics
NPI:1508851411
Name:JACKOWITZ, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:JACKOWITZ
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 1:3640 MAIN ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1145
Mailing Address - Country:US
Mailing Address - Phone:413-739-7367
Mailing Address - Fax:413-737-2686
Practice Address - Street 1:3640 MAIN ST
Practice Address - Street 2:SUITE 205
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1145
Practice Address - Country:US
Practice Address - Phone:413-739-7367
Practice Address - Fax:413-737-2686
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0115328OtherAETNA GROUP NO.
MAJ06214OtherMASS BLUE SHIELD
MA0034216003OtherCIGNA
MA010057126MA01OtherCONNECTICUT BLUE SHIELD
MA150664OtherHARVARD PILGRIM
MA032587OtherCONNECTICARE
MA0804490OtherUNITED HEALTH CARE
MA13334OtherHEALTH NEW ENGLAND
MAP1500300OtherOXFORD HEALTH PLANS
MA180012328OtherRAILROAD MEDICARE
MA13334OtherHEALTH NEW ENGLAND
MAP1500300OtherOXFORD HEALTH PLANS