Provider Demographics
NPI:1588762132
Name:JACK FAUP MD PA
Entity type:Organization
Organization Name:JACK FAUP MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAUP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-299-3160
Mailing Address - Street 1:1515 PARK CENTER DR
Mailing Address - Street 2:SUITE 2-I
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5794
Mailing Address - Country:US
Mailing Address - Phone:407-299-3160
Mailing Address - Fax:407-299-2445
Practice Address - Street 1:1515 PARK CENTER DR
Practice Address - Street 2:SUITE 2-I
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5794
Practice Address - Country:US
Practice Address - Phone:407-299-3160
Practice Address - Fax:407-299-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15851207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048731700Medicaid
FL048731700Medicaid
FLD64211Medicare UPIN