Provider Demographics
NPI:1659674703
Name:JACKOWITZ, MICHAEL S (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:JACKOWITZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 WAILEA IKE DR
Mailing Address - Street 2:URGENT CARE
Mailing Address - City:WAILEA
Mailing Address - State:HI
Mailing Address - Zip Code:96753-9524
Mailing Address - Country:US
Mailing Address - Phone:808-281-6580
Mailing Address - Fax:808-244-4418
Practice Address - Street 1:100 WAILEA IKE DR
Practice Address - Street 2:URGENT CARE
Practice Address - City:WAILEA
Practice Address - State:HI
Practice Address - Zip Code:96753-9524
Practice Address - Country:US
Practice Address - Phone:808-281-6580
Practice Address - Fax:808-244-4418
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2014-05-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY190476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02080968Medicaid
NYG95405Medicare UPIN