Healthcare Provider Details

I. General information

NPI: 1568763555
Provider Name (Legal Business Name): JAN S. JURNECKA, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 SKYWARD DR
APTOS CA
95003-3014
US

IV. Provider business mailing address

405 SKYWARD DR
APTOS CA
95003-3014
US

V. Phone/Fax

Practice location:
  • Phone: 831-688-4034
  • Fax:
Mailing address:
  • Phone: 831-688-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG52392
License Number StateCA

VIII. Authorized Official

Name: DR. JAN JURNECKA
Title or Position: PRESIDENT
Credential:
Phone: 831-688-4034