Provider Demographics
NPI:1346227774
Name:SCHMETTERLING, JACK A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:SCHMETTERLING
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 1:336 N MAIN ST
Mailing Address - Street 2:HARTFORD MEDICAL GROUP
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2510
Mailing Address - Country:US
Mailing Address - Phone:860-232-4891
Mailing Address - Fax:860-236-1016
Practice Address - Street 1:336 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2510
Practice Address - Country:US
Practice Address - Phone:860-232-4891
Practice Address - Fax:860-263-1016
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2045171207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001267500Medicaid
CT001267500Medicaid
D98109Medicare UPIN
700004964Medicare PIN