Healthcare Provider Details

I. General information

NPI: 1659416741
Provider Name (Legal Business Name): JACK OSCAR PIASECKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 IRVINE BLVD SUITE L
TUSTIN CA
92780-3030
US

IV. Provider business mailing address

17400 IRVINE BLVD SUITE L
TUSTIN CA
92780-3030
US

V. Phone/Fax

Practice location:
  • Phone: 714-508-1112
  • Fax: 714-508-3653
Mailing address:
  • Phone: 714-508-1112
  • Fax: 714-508-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG53516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: