Basic Information
| Provider Information | |||||||||
| NPI: | 1962403188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SACKS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3725 11TH CR | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725620163 | ||||||||
| FaxNumber: | 7725675631 | ||||||||
| Practice Location | |||||||||
| Address1: | 3725 11TH CR | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725620163 | ||||||||
| FaxNumber: | 7725675631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
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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 | ME88014 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 71162 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER | 267458100 | 05 | FL | MEDICAID |