Provider Demographics
NPI:1730140666
Name:STERN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:STERN
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:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14851-0515
Mailing Address - Country:US
Mailing Address - Phone:855-522-7233
Mailing Address - Fax:914-206-4590
Practice Address - Street 1:915 BROADWAY
Practice Address - Street 2:STE 1200
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7108
Practice Address - Country:US
Practice Address - Phone:212-228-4002
Practice Address - Fax:914-206-4590
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY124524207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB73799Medicare UPIN