Provider Demographics
NPI:1306804703
Name:PEARL, JACK W (DO)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:PEARL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9398 N LILLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4610
Mailing Address - Country:US
Mailing Address - Phone:734-459-2255
Mailing Address - Fax:734-459-1855
Practice Address - Street 1:9398 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4610
Practice Address - Country:US
Practice Address - Phone:734-459-2255
Practice Address - Fax:734-459-1855
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101004511207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2628611Medicaid
MI0N70250Medicare ID - Type Unspecified
MI2628611Medicaid