Provider Demographics
NPI:1689644031
Name:PRESTON, JACK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:PRESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3572 BRODHEAD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3101
Mailing Address - Country:US
Mailing Address - Phone:724-728-6539
Mailing Address - Fax:724-728-7416
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-4567
Practice Address - Fax:724-728-9729
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027545E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009554740018Medicaid
WV3810003945Medicaid
PA000955474Medicaid
OH2233292Medicaid
OH2233292Medicaid
PA300115212Medicare PIN
PA0009554740018Medicaid
PA000955474Medicaid
OHPR4115611Medicare PIN