Provider Demographics
NPI:1265573018
Name:JACK PFEILSTICKER M D P A
Entity type:Organization
Organization Name:JACK PFEILSTICKER M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:PFEILSTICKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-747-2282
Mailing Address - Street 1:4701 MANATEE AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3851
Mailing Address - Country:US
Mailing Address - Phone:941-747-2282
Mailing Address - Fax:941-757-0656
Practice Address - Street 1:4701 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3851
Practice Address - Country:US
Practice Address - Phone:941-747-2282
Practice Address - Fax:941-757-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46226261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266225600Medicaid
FL266225600Medicaid
FLK5861Medicare ID - Type Unspecified