Provider Demographics
NPI:1518929439
Name:BREWER, JACK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALAN
Last Name:BREWER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2090 NE WYATT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7687
Mailing Address - Country:US
Mailing Address - Phone:541-382-6447
Mailing Address - Fax:541-330-7413
Practice Address - Street 1:2090 NE WYATT CT
Practice Address - Street 2:SUITE 101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7687
Practice Address - Country:US
Practice Address - Phone:541-382-6447
Practice Address - Fax:541-330-7413
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD14911208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR113050Medicaid
C92282Medicare UPIN
R101477Medicare PIN