Provider Demographics
NPI:1013953439
Name:SCHWARTZWALD, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:SCHWARTZWALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02880-0229
Mailing Address - Country:US
Mailing Address - Phone:401-788-3337
Mailing Address - Fax:401-788-3939
Practice Address - Street 1:100 KENYON AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4216
Practice Address - Country:US
Practice Address - Phone:401-788-1590
Practice Address - Fax:401-788-1593
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD08226208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006672Medicaid
RI007056282Medicare PIN