1699750075 NPI number — DANIEL MARK JACQUES MD

Table of content: DANIEL MARK JACQUES MD (NPI 1699750075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699750075 NPI number — DANIEL MARK JACQUES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACQUES
Provider First Name:
DANIEL
Provider Middle Name:
MARK
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:
JACQUES
Provider Other First Name:
DANIEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1699750075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 VERDAE BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29607-4032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-242-4683
Provider Business Mailing Address Fax Number:
864-240-8104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 ST. FRANCIS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-232-8118
Provider Business Practice Location Address Fax Number:
864-370-2740
Provider Enumeration Date:
12/08/2005

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:  17921 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20051085 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 179210 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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