Provider Demographics
NPI:1124038856
Name:DEESE, JACK MELVIN JR (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MELVIN
Last Name:DEESE
Suffix:JR
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 1:3025 SHRINE RD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4784
Mailing Address - Country:US
Mailing Address - Phone:912-466-7340
Mailing Address - Fax:912-466-7358
Practice Address - Street 1:3025 SHRINE RD
Practice Address - Street 2:SUITE 390
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4784
Practice Address - Country:US
Practice Address - Phone:912-466-7340
Practice Address - Fax:912-466-7358
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24534207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45202Medicare UPIN