Provider Demographics
NPI:1497713747
Name:LURTON, JACK WALTER JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WALTER
Last Name:LURTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14 W JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1736
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:14 W JORDAN ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1736
Practice Address - Country:US
Practice Address - Phone:850-436-4630
Practice Address - Fax:850-436-2095
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME11915207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036679000Medicaid
FLE11915Medicare UPIN