Provider Demographics
NPI:1093988008
Name:SHIRES, JAY GORDON (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:GORDON
Last Name:SHIRES
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:PO BOX 11942
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0132
Mailing Address - Country:US
Mailing Address - Phone:731-660-2665
Mailing Address - Fax:731-660-2121
Practice Address - Street 1:294 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3915
Practice Address - Country:US
Practice Address - Phone:731-423-1932
Practice Address - Fax:731-265-8355
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000045650207P00000X
TN45650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519909Medicaid
TN103I087674Medicare PIN