Provider Demographics
NPI:1689052482
Name:JACK ANDREW HARVEY DPM, INC.
Entity Type:Organization
Organization Name:JACK ANDREW HARVEY DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-823-2700
Mailing Address - Street 1:1210 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4962
Mailing Address - Country:US
Mailing Address - Phone:209-823-2700
Mailing Address - Fax:209-823-2779
Practice Address - Street 1:1210 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4962
Practice Address - Country:US
Practice Address - Phone:209-823-2700
Practice Address - Fax:209-823-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5204213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty