Provider Demographics
NPI:1558456426
Name:ANSTANDIG, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:ANSTANDIG
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 1:34900 CHARDON ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094
Mailing Address - Country:US
Mailing Address - Phone:440-269-1550
Mailing Address - Fax:440-269-1750
Practice Address - Street 1:34900 CHARDON ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-269-1550
Practice Address - Fax:440-269-1750
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0521462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0819994Medicaid
E77456Medicare UPIN
OH0819994Medicaid