Provider Demographics
NPI:1558003293
Name:KILGORE, JACK ELDON III (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ELDON
Last Name:KILGORE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 E BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-6824
Mailing Address - Country:US
Mailing Address - Phone:239-896-8415
Mailing Address - Fax:
Practice Address - Street 1:2201 CHILDRENS WAY STE 1221
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-3164
Practice Address - Country:US
Practice Address - Phone:615-322-0738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program