Provider Demographics
NPI:1619996204
Name:ADLER, JACK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:JOSEPH
Last Name:ADLER
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 1:19 E 80TH ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-0117
Mailing Address - Country:US
Mailing Address - Phone:212-535-3622
Mailing Address - Fax:212-452-2808
Practice Address - Street 1:19 E 80TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0117
Practice Address - Country:US
Practice Address - Phone:212-535-3622
Practice Address - Fax:212-452-2808
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY98677174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY916012Medicare ID - Type Unspecified
NYC12304Medicare UPIN