Provider Demographics
NPI:1215001581
Name:IRELAND, JACK EATON (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EATON
Last Name:IRELAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2021 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2219
Mailing Address - Country:US
Mailing Address - Phone:972-253-2560
Mailing Address - Fax:972-253-4218
Practice Address - Street 1:2021 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2219
Practice Address - Country:US
Practice Address - Phone:972-253-4215
Practice Address - Fax:972-253-4227
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039169001Medicaid
TXB23705Medicare UPIN
TX818152Medicare PIN