Provider Demographics
NPI:1174106843
Name:HUNT, JACK FARO VANDER STOEP
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:FARO VANDER STOEP
Last Name:HUNT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DICKINSON ST.
Mailing Address - Street 2:MC# 8218
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-471-0283
Mailing Address - Fax:619-543-2092
Practice Address - Street 1:200 DICKINSON ST.
Practice Address - Street 2:MC# 8218
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-471-0283
Practice Address - Fax:619-543-2092
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program