Individual
JACK PHILIP TOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
207 HALLOCK RD, SUITE 211, STONY BROOK, NY 11790-3033
(631) 444-0004
(631) 444-0088
Mailing address
207 HALLOCK RD, SUITE 211, STONY BROOK, NY 11790-3033
(631) 444-0004
(631) 444-0088
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
155342
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01711760
—
NY
Enumeration date
08/05/2006
Last updated
07/08/2007
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