Provider Demographics
NPI:1023034972
Name:CARMACK, JOHN TIMOTHY (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TIMOTHY
Last Name:CARMACK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 MAIDENS RD
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-4015
Mailing Address - Country:US
Mailing Address - Phone:804-928-8167
Mailing Address - Fax:
Practice Address - Street 1:618 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-6297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045525207P00000X, 207Q00000X
LAMD.09541R207P00000X
WV30744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005639301Medicaid
VA005829623Medicaid
VA1023034972Medicaid
VA080006947Medicare PIN
VA080007018Medicare PIN
VA022321E98Medicare PIN
VA1023034972Medicaid