Basic Information
| Provider Information | |||||||||
| NPI: | 1447503826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACK | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MEDICAL PLZ | ||||||||
| Address2: | 140 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108251172 | ||||||||
| FaxNumber: | 3107940987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 15TH ST | ||||||||
| Address2: | 1200 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904041135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107947700 | ||||||||
| FaxNumber: | 3109395302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A83253 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1447503826 | 05 | CA | MEDICAID |