Provider Demographics
NPI:1497756662
Name:JACK, WM DAVID II (MD)
Entity Type:Individual
Prefix:
First Name:WM DAVID
Middle Name:
Last Name:JACK
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1521 SOUTH STAPLES
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3160
Mailing Address - Country:US
Mailing Address - Phone:361-888-8271
Mailing Address - Fax:361-885-3699
Practice Address - Street 1:1521 SOUTH STAPLES
Practice Address - Street 2:SUITE 700
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-3160
Practice Address - Country:US
Practice Address - Phone:361-888-8271
Practice Address - Fax:361-885-3699
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE3023207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129677404Medicaid
TXC17329Medicare UPIN
TX129677404Medicaid