Provider Demographics
NPI:1063594950
Name:HADAM, JACK TOMASZ (DPT)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:TOMASZ
Last Name:HADAM
Suffix:
Gender:M
Credentials:DPT
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 396
Mailing Address - Street 2:
Mailing Address - City:CHOCORUA
Mailing Address - State:NH
Mailing Address - Zip Code:03817-0396
Mailing Address - Country:US
Mailing Address - Phone:603-244-0125
Mailing Address - Fax:
Practice Address - Street 1:685 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:TAMWORTH
Practice Address - State:NH
Practice Address - Zip Code:03886-4638
Practice Address - Country:US
Practice Address - Phone:603-323-2089
Practice Address - Fax:603-323-2097
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1953173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHHA RE7092Medicare ID - Type Unspecified