Provider Demographics
NPI:1770596975
Name:JACK FATIHA MD PC
Entity type:Organization
Organization Name:JACK FATIHA MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FATIHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-336-0100
Mailing Address - Street 1:709 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4133
Mailing Address - Country:US
Mailing Address - Phone:718-336-0100
Mailing Address - Fax:718-336-7139
Practice Address - Street 1:709 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4133
Practice Address - Country:US
Practice Address - Phone:718-336-0100
Practice Address - Fax:718-336-7139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229099261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1619969177OtherINDIVIDUAL NPI #