Provider Demographics
NPI:1629006531
Name:AMATO, JACK C (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:AMATO
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 1:7880 LINCOLE PL
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-8322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16687 SAINT CLAIR AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9401
Practice Address - Country:US
Practice Address - Phone:330-424-7221
Practice Address - Fax:330-424-3731
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036022207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000371276OtherANTHEM BLUE SHIELD
OH0298959Medicaid
OH0298959Medicaid
A14838Medicare UPIN