Provider Demographics
NPI:1306289129
Name:JACK, RICHARD ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTHONY
Last Name:JACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-708-5570
Practice Address - Fax:818-708-5471
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAC1758892080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program