Provider Demographics
NPI:1558363234
Name:FORD, JACK (M D)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 AUSTIN BLUFFS PKWY STE 306
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5755
Mailing Address - Country:US
Mailing Address - Phone:719-475-1810
Mailing Address - Fax:719-475-1812
Practice Address - Street 1:3505 AUSTIN BLUFFS PKWY STE 306
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5755
Practice Address - Country:US
Practice Address - Phone:719-475-1810
Practice Address - Fax:719-475-1812
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0016135207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01161355Medicaid
CO30051Medicare ID - Type Unspecified
COD22996Medicare UPIN