MEDICARE: JACK Z NUSSBAUM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	165161	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346242690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK Z NUSSBAUM MD

Provider Business Mailing Address
First Line	:	388 HAWKINS AVE
Second Line	:	STE 1
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4280
Country	:	US
Telephone Number	:	631-588-8460
Fax Number	:	631-588-8480

Provider Business Practice Location Address
First Line	:	388 HAWKINS AVE
Second Line	:	STE 1
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4280
Country	:	US
Telephone Number	:	631-588-8460
Fax Number	:	631-588-8480

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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