Provider Demographics
NPI:1578581971
Name:MADOWITZ, JACK STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:STUART
Last Name:MADOWITZ
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 1:8851 CENTER DR STE 312
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3050
Mailing Address - Country:US
Mailing Address - Phone:619-667-0708
Mailing Address - Fax:619-667-5343
Practice Address - Street 1:8851 CENTER DR STE 312
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3050
Practice Address - Country:US
Practice Address - Phone:619-667-0708
Practice Address - Fax:619-667-5343
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48385Medicare UPIN
CAW14888Medicare PIN