Provider Demographics
NPI:1558366955
Name:SHUMATE, JACK B JR (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:B
Last Name:SHUMATE
Suffix:JR
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 1:100 DOCTORS DR
Mailing Address - Street 2:STE B
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7609
Mailing Address - Country:US
Mailing Address - Phone:850-872-1300
Mailing Address - Fax:850-872-9420
Practice Address - Street 1:100 DOCTORS DR
Practice Address - Street 2:STE B
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7609
Practice Address - Country:US
Practice Address - Phone:850-872-1300
Practice Address - Fax:850-872-9420
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME213902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68004OtherBLUE CROSS BLUE SHIELD
FLC02217Medicare UPIN
FL68004OtherBLUE CROSS BLUE SHIELD