Provider Demographics
NPI:1417059924
Name:FORD, JACK O (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:O
Last Name:FORD
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 1:700 W GOLD ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2320
Mailing Address - Country:US
Mailing Address - Phone:406-782-6391
Mailing Address - Fax:406-782-6585
Practice Address - Street 1:700 W GOLD ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2320
Practice Address - Country:US
Practice Address - Phone:406-782-6391
Practice Address - Fax:406-782-6585
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10733204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0095438Medicaid
MT99955OtherBLUE CROSS BLUE SHIELD
MT99955OtherBLUE CROSS BLUE SHIELD