Provider Demographics
NPI:1851749766
Name:O'BRIEN, JACK (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:DO
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 ROBERTSON BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2145
Mailing Address - Country:US
Mailing Address - Phone:310-652-2562
Mailing Address - Fax:
Practice Address - Street 1:150 N ROBERTSON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2145
Practice Address - Country:US
Practice Address - Phone:310-652-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine