Provider Demographics
NPI:1821082389
Name:CHEN, JACK P (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:CHEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5670 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:STE 880
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4789
Mailing Address - Country:US
Mailing Address - Phone:404-256-2525
Mailing Address - Fax:404-256-9589
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD STE 880
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4789
Practice Address - Country:US
Practice Address - Phone:404-256-2525
Practice Address - Fax:404-256-9589
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2020-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA040031207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000659788BMedicaid
GAF49412Medicare UPIN
GA11BDPXZMedicare ID - Type Unspecified