Basic Information
| Provider Information | |||||||||
| NPI: | 1245304328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACK WAX, M.D., INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 CENTURY PARK E | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900672001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102771846 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WAX | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT-SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8188887815 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A28870 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | A28870 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.