Individual
GREGORY SCOTT JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1260 15TH ST, 1200, SANTA MONICA, CA 90404-1135
(310) 794-7700
(310) 939-5302
Mailing address
200 MEDICAL PLZ, 140, LOS ANGELES, CA 90095-0001
(310) 825-1172
(310) 794-0987
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
A83253
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1447503826
—
CA
Enumeration date
10/22/2012
Last updated
01/30/2013
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