Healthcare Provider Details

I. General information

NPI: 1164511051
Provider Name (Legal Business Name): JACK SANFORD NADLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 BIRCH STREET
LAKE ISABELLA CA
93240
US

IV. Provider business mailing address

PO BOX 91
KERNVILLE CA
93238-0091
US

V. Phone/Fax

Practice location:
  • Phone: 760-379-1791
  • Fax:
Mailing address:
  • Phone: 760-417-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAO63717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: