Provider Demographics
NPI:1588662241
Name:SOBRIN, JACK J (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:SOBRIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-0307
Mailing Address - Country:US
Mailing Address - Phone:845-723-4499
Mailing Address - Fax:
Practice Address - Street 1:1539 MAIN ST UNIT D
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-7834
Practice Address - Country:US
Practice Address - Phone:845-723-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205611208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01832177Medicaid
NYA400116481Medicare PIN
NY545522Medicare PIN
NYG65888Medicare UPIN