Provider Demographics
NPI:1013950104
Name:MURCIANO, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MURCIANO
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 1:900 S PINE ISLAND RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3920
Mailing Address - Country:US
Mailing Address - Phone:954-741-4280
Mailing Address - Fax:954-741-4912
Practice Address - Street 1:4279 NW 88TH AVE
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6044
Practice Address - Country:US
Practice Address - Phone:954-741-4280
Practice Address - Fax:954-741-4912
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212728208000000X
FLME77125208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280927300Medicaid