Provider Demographics
NPI:1568503548
Name:MESQUITE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:MESQUITE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PIOTR
Authorized Official - Middle Name:
Authorized Official - Last Name:JAKUBOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-613-3700
Mailing Address - Street 1:2379 GUS THOMASSON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-5302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2379 GUS THOMASSON RD STE 300
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5302
Practice Address - Country:US
Practice Address - Phone:972-613-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181892401Medicaid
TX07NHOtherBCBS OF TEXAS
TX181892401Medicaid