Provider Demographics
NPI:1487656245
Name:VAN GEFFEN, JACK J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:VAN GEFFEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PKWY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-266-2770
Mailing Address - Fax:410-841-6251
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE 235
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-266-2770
Practice Address - Fax:410-841-6251
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00199672085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10690008OtherBCBS
MD1487656245OtherMEDICARE SHIPLEYS IMAGING
MD300031317OtherTRAVELERS RR MEDICARE
MDA14OtherAAD PG COUNTY
MD414894ZED1OtherPTAN DC BOWIE
MD8317071OtherAETNA PPO
MD155951600Medicaid
MD2622593OtherAETNA HMO/POS
MD494MOtherAAD SHIPLEYS
MDJG95OtherAAD AA COUNTY
MDA14OtherAAD PG COUNTY
MD300135424Medicare PIN
MD300031317Medicare PIN
MD1487656245OtherMEDICARE SHIPLEYS IMAGING
MDJG95OtherAAD AA COUNTY