Provider Demographics
NPI:1770071128
Name:YUAN, JACK (DPM)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:YUAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CENTRE ST STE 702
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4557
Mailing Address - Country:US
Mailing Address - Phone:212-226-6888
Mailing Address - Fax:212-226-8805
Practice Address - Street 1:139 CENTRE ST STE 702
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4557
Practice Address - Country:US
Practice Address - Phone:212-226-6888
Practice Address - Fax:212-226-8805
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006983-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery