Provider Demographics
NPI:1023170636
Name:DODICK, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DODICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8198
Mailing Address - Country:US
Mailing Address - Phone:212-288-7638
Mailing Address - Fax:212-832-0640
Practice Address - Street 1:535 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8198
Practice Address - Country:US
Practice Address - Phone:212-288-7638
Practice Address - Fax:212-832-0640
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105324207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB16906Medicare UPIN
NY581151Medicare PIN