Provider Demographics
NPI:1477549376
Name:COLE, JACK CECIL (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:CECIL
Last Name:COLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 HEMBY LANE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3777
Mailing Address - Country:US
Mailing Address - Phone:252-551-3000
Mailing Address - Fax:252-551-3000
Practice Address - Street 1:2210 HEMBY LANE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3777
Practice Address - Country:US
Practice Address - Phone:252-551-3000
Practice Address - Fax:252-551-3000
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33916207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE82103Medicare UPIN
NC2402703Medicare ID - Type Unspecified