Provider Demographics
NPI:1952744104
Name:JACK, ANYANATE GWENDOLYNE (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:ANYANATE
Middle Name:GWENDOLYNE
Last Name:JACK
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:DR
Other - First Name:GWENDOLYNE
Other - Middle Name:ANYANATE
Other - Last Name:JACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:525 E 68TH ST # 2026
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 E 80TH ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075
Practice Address - Country:US
Practice Address - Phone:646-962-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2928521207RE0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program