Provider Demographics
NPI:1801932280
Name:SASIENE, JACK ALLAN (DPM)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALLAN
Last Name:SASIENE
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:PO BOX 58538
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-8538
Mailing Address - Country:US
Mailing Address - Phone:409-948-4848
Mailing Address - Fax:409-948-6042
Practice Address - Street 1:3200 PALMER HWY
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-6724
Practice Address - Country:US
Practice Address - Phone:409-948-4848
Practice Address - Fax:409-948-6042
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1200213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1041500001OtherDME PROVIDER
TX121549301Medicaid
TX121549303Medicaid
TX00T13AMedicare PIN
TX00022EMedicare PIN
TX121549303Medicaid