Provider Demographics
NPI:1669475489
Name:MORGAN, JACK (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MORGAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N GARFIELD AVE
Mailing Address - Street 2:STE 108
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1242
Mailing Address - Country:US
Mailing Address - Phone:626-288-2760
Mailing Address - Fax:626-571-6211
Practice Address - Street 1:500 N GARFIELD AVE
Practice Address - Street 2:STE 108
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1242
Practice Address - Country:US
Practice Address - Phone:626-288-2760
Practice Address - Fax:626-571-6211
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1613213ES0131X, 213ES0103X, 213ES0000X, 213EP1101X, 213E00000X
CAE1614213ER0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E16131Medicaid
CAWE11844Medicare ID - Type Unspecified
CA000E16131Medicaid