Provider Demographics
NPI:1306914783
Name:WASSERMAN, JACK (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:WASSERMAN
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 1:9999 MIRA MESA BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1006
Mailing Address - Country:US
Mailing Address - Phone:858-271-6962
Mailing Address - Fax:858-271-5327
Practice Address - Street 1:9999 MIRA MESA BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1006
Practice Address - Country:US
Practice Address - Phone:858-271-6962
Practice Address - Fax:858-271-5327
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30311OtherLICENSE
CAWA30311AMedicare ID - Type Unspecified
CAG30311OtherLICENSE