Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | G53516 | CA |
NPI | 1659416741 |
---|---|
Provider Name | Dr. Jack Oscar Piasecki |
First Address | Tustin, CA 92780-3030 |
Second Address | Tustin, CA 92780-3030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D47810 | (02) |