Provider Demographics
NPI:1447214382
Name:CROWDER, JACK R (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:CROWDER
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 1:2002 BROOKSIDE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4634
Mailing Address - Country:US
Mailing Address - Phone:423-392-6370
Mailing Address - Fax:423-392-6736
Practice Address - Street 1:2002 BROOKSIDE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
Practice Address - Country:US
Practice Address - Phone:423-392-6370
Practice Address - Fax:423-392-6736
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD07408207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2005847OtherBCBS
TN3160026Medicaid
TNTN01L6OtherJOHN DEERE
TN2005847OtherBCBS
TN3160026Medicaid