Provider Demographics
NPI:1659416741
Name:PIASECKI, JACK OSCAR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:OSCAR
Last Name:PIASECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:17400 IRVINE BLVD
Mailing Address - Street 2:SUITE L
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3030
Mailing Address - Country:US
Mailing Address - Phone:714-508-1112
Mailing Address - Fax:714-508-3653
Practice Address - Street 1:17400 IRVINE BLVD
Practice Address - Street 2:SUITE L
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-508-1112
Practice Address - Fax:714-508-3653
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG53516204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D47810Medicare UPIN
WG53516AMedicare ID - Type UnspecifiedPPIN
W19690Medicare ID - Type Unspecified