Provider Demographics
NPI:1891899423
Name:SIOPACK, JORGE SIMON (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:SIMON
Last Name:SIOPACK
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 1:1601 FRUITVALE AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:515-535-4128
Practice Address - Street 1:3451 E 12TH STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:510-535-3317
Practice Address - Fax:510-535-4248
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62179207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP71021FOtherFPACT
CAZZZ29799ZOtherMEDICARE PART B
55-1975OtherMEDICARE PART A
CAFHC71021FMedicaid
55-1975OtherMEDICARE PART A