Provider Demographics
NPI:1215016324
Name:FOLTZ, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:FOLTZ
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 1:8211 W STATE ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2534
Mailing Address - Country:US
Mailing Address - Phone:812-716-2786
Mailing Address - Fax:812-858-1001
Practice Address - Street 1:8211 W STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2534
Practice Address - Country:US
Practice Address - Phone:812-716-2786
Practice Address - Fax:812-858-1001
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023186A207VG0400X, 208D00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1312001Medicare PIN
INB29194Medicare UPIN