Provider Demographics
NPI:1265416424
Name:DRUET, JACK JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:JACOB
Last Name:DRUET
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 893520
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-3520
Mailing Address - Country:US
Mailing Address - Phone:951-699-0303
Mailing Address - Fax:951-699-0603
Practice Address - Street 1:25495 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5963
Practice Address - Country:US
Practice Address - Phone:951-506-9536
Practice Address - Fax:951-693-4631
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70999207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC4371OtherRAILROAD MEDICARE GRP #
CAP00168751OtherRAILROAD MEDICARE
CAP00168751OtherRAILROAD MEDICARE
F81979Medicare UPIN
CABD4190889OtherDEA