Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 35 025358 | OH |
NPI | 1053478453 |
---|---|
Provider Name | Dr. Jack Walter Jaffe |
First Address | Shaker Heights, OH 44122-2116 |
Second Address | Shaker Heights, OH 44122-2116 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
35 025358 | STATE LICENSE (01) | OH |