Healthcare Provider Details

I. General information

NPI: 1265416424
Provider Name (Legal Business Name): JACK JACOB DRUET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25495 MEDICAL CENTER DR SUITE 102
MURRIETA CA
92562-5963
US

IV. Provider business mailing address

PO BOX 893520
TEMECULA CA
92589-3520
US

V. Phone/Fax

Practice location:
  • Phone: 951-506-9536
  • Fax: 951-693-4631
Mailing address:
  • Phone: 951-699-0303
  • Fax: 951-699-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG70999
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG70999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: