Provider Demographics
NPI:1265401541
Name:SCHILLEN, JACK DAVID (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:DAVID
Last Name:SCHILLEN
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:PO BOX 991950
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-1950
Mailing Address - Country:US
Mailing Address - Phone:530-246-2467
Mailing Address - Fax:530-242-9460
Practice Address - Street 1:1255 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0814
Practice Address - Country:US
Practice Address - Phone:530-246-2467
Practice Address - Fax:530-242-9460
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91728207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079250Medicaid
H61042Medicare UPIN
CA00A917281Medicare PIN
CAGR0079250Medicaid