Provider Demographics
NPI:1609819622
Name:WACK, JON PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:PHILLIP
Last Name:WACK
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:P.O. BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:
Practice Address - Street 1:3700 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1618
Practice Address - Country:US
Practice Address - Phone:415-750-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA233132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1609819622Medicaid
CA300134151OtherRAILROAD MEDICARE
CA00A233130Medicaid
CA00A233133Medicare PIN
CABH121ZMedicare PIN
CA00A233132Medicare PIN
CA00A233134Medicare PIN
CA300134151OtherRAILROAD MEDICARE
CA00A233130Medicaid
CA00A233131Medicare PIN