Provider Demographics
NPI:1275534851
Name:HOFFNUNG, JACK M (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:HOFFNUNG
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 1:3053 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1720
Mailing Address - Country:US
Mailing Address - Phone:423-968-1144
Mailing Address - Fax:423-968-3453
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-968-1144
Practice Address - Fax:423-968-3453
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN153162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA242045OtherANTHEM BCBS
TN3058534OtherBCBS
TNR07104OtherJOHN DEERE
KY64927460Medicaid
VA7213395Medicaid
WV0216840000Medicaid
TN3193230Medicaid
KY64927460Medicaid
B04511Medicare UPIN