Provider Demographics
NPI:1932288818
Name:AGIN, JACK GUY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:GUY
Last Name:AGIN
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 1:63 WHITE COVE WALK
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-4026
Mailing Address - Country:US
Mailing Address - Phone:516-799-4877
Mailing Address - Fax:
Practice Address - Street 1:63 WHITE COVE WALK
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-4026
Practice Address - Country:US
Practice Address - Phone:516-799-4877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087869207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism