Provider Demographics
NPI:1154402188
Name:NUSZEN, JACK A (DO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:NUSZEN
Suffix:
Gender:M
Credentials:DO
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 24125
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1125
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:SUITE M 196
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-790-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3811207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00174597OtherRAIL ROAD MEDICARE
TX118503510Medicaid
TX118503512Medicaid
TX8P5339OtherBLUE CROSS & BLUE SHIELD
TXP00311999OtherRAIL ROAD MEDICARE
TXG48161Medicare UPIN
TXP00174597OtherRAIL ROAD MEDICARE
TX118503512Medicaid