Provider Demographics
NPI:1356431779
Name:SACKS, JAY G (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:G
Last Name:SACKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S UNION AVE
Mailing Address - Street 2:#B1
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1907
Mailing Address - Country:US
Mailing Address - Phone:253-475-2601
Mailing Address - Fax:253-572-8224
Practice Address - Street 1:1310 S UNION AVE
Practice Address - Street 2:#B1
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1907
Practice Address - Country:US
Practice Address - Phone:253-475-2601
Practice Address - Fax:253-572-8224
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA14616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA757081059OtherRAILROAD MEDICARE
WA1306307Medicaid
WA0016337OtherL&I
WASA3808OtherREGENCE
WA757081059OtherRAILROAD MEDICARE
WAG001001041Medicare ID - Type Unspecified