Provider Demographics
NPI:1447503826
Name:JACK, GREGORY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:JACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:200 MEDICAL PLZ
Mailing Address - Street 2:140
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-825-1172
Mailing Address - Fax:310-794-0987
Practice Address - Street 1:1260 15TH ST
Practice Address - Street 2:1200
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1135
Practice Address - Country:US
Practice Address - Phone:310-794-7700
Practice Address - Fax:310-939-5302
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2013-01-30
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Provider Licenses
StateLicense IDTaxonomies
CAA83253208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447503826Medicaid
CAGU156ZMedicare PIN