Basic Information
| Provider Information | |||||||||
| NPI: | 1609819622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WACK | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | PHILLIP | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 6102 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949486102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158843418 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3700 CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941181618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157506025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A23313 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1609819622 | 05 | NV | MEDICAID | 300134151 | 01 | CA | RAILROAD MEDICARE | OTHER | 00A233130 | 05 | CA | MEDICAID |