Provider Demographics
NPI:1184828030
Name:JACKS, SAMUEL PORTER (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PORTER
Last Name:JACKS
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-768-9535
Mailing Address - Fax:336-768-4155
Practice Address - Street 1:4622 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 180
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3769
Practice Address - Country:US
Practice Address - Phone:336-768-9535
Practice Address - Fax:336-768-4155
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01953208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005979900Medicaid
GA003125978AMedicaid
FLP01084809OtherRAILROAD MEDICARE
FL005979900Medicaid