Provider Demographics
NPI:1285635474
Name:CARMAN, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CARMAN
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 1:3145 W CLARK RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1120
Mailing Address - Country:US
Mailing Address - Phone:734-528-5749
Mailing Address - Fax:
Practice Address - Street 1:3145 W CLARK RD
Practice Address - Street 2:SUITE 401
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1120
Practice Address - Country:US
Practice Address - Phone:734-528-5749
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJC030127207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID83119Medicare UPIN
MIN70790007Medicare ID - Type Unspecified