Provider Demographics
NPI:1568484152
Name:ERWIN, JACK ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ROY
Last Name:ERWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4740 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1615
Mailing Address - Country:US
Mailing Address - Phone:936-569-8246
Mailing Address - Fax:936-564-3246
Practice Address - Street 1:4740 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1615
Practice Address - Country:US
Practice Address - Phone:936-569-8246
Practice Address - Fax:936-564-3246
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXD4105207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD4106OtherLICENSE
TXD4106OtherLICENSE
00N513Medicare ID - Type Unspecified