Provider Demographics
NPI:1689639577
Name:FISHENFELD, JACO (MD)
Entity Type:Individual
Prefix:
First Name:JACO
Middle Name:
Last Name:FISHENFELD
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 1:150 N JACKSON AVENUE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1907
Mailing Address - Country:US
Mailing Address - Phone:408-926-2200
Mailing Address - Fax:408-926-6876
Practice Address - Street 1:150 N JACKSON AVENUE
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1907
Practice Address - Country:US
Practice Address - Phone:408-926-2200
Practice Address - Fax:408-926-6876
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A24503Medicare UPIN
CA00A255750Medicare ID - Type Unspecified