1710063573 NPI number — GREGORY J JURKOVICH MD

Table of content: GREGORY J JURKOVICH MD (NPI 1710063573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710063573 NPI number — GREGORY J JURKOVICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JURKOVICH
Provider First Name:
GREGORY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710063573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 STOCKTON BLVD., CYPRESS BLDG. 3RD FLOOR
Provider Second Line Business Mailing Address:
SUITE 3111
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95817-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-734-3510
Provider Business Mailing Address Fax Number:
916-734-7089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2221 STOCKTON BLVD., CYPRESS TRAUMA SURGERY CLINIC
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95817-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-3510
Provider Business Practice Location Address Fax Number:
916-734-7089
Provider Enumeration Date:
10/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD00025766 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: MD00025766 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0102X , with the licence number: MD00025766 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: 141002 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0102X , with the licence number: 141002 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 141002 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8141 . This is a "INTERNAL ID-MOTOR VEHICLE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 020027093 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710063573 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".