Provider Demographics
NPI:1386735249
Name:KABAK, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KABAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1225 CRANE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4253
Mailing Address - Country:US
Mailing Address - Phone:650-324-0056
Mailing Address - Fax:650-324-1156
Practice Address - Street 1:1225 CRANE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4253
Practice Address - Country:US
Practice Address - Phone:650-324-1156
Practice Address - Fax:650-324-1156
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA29333207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A293330Medicaid
CA00A293331Medicare PIN
CAA25721Medicare UPIN
CA00A293330Medicaid
A25721Medicare UPIN