Provider Demographics
NPI:1568859510
Name:PINES, JACK R III (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:PINES
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 1:105 REGENCY PARK DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6649
Mailing Address - Country:US
Mailing Address - Phone:770-506-4119
Mailing Address - Fax:
Practice Address - Street 1:105 REGENCY PARK DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6649
Practice Address - Country:US
Practice Address - Phone:770-506-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPGY.203100208100000X
390200000X
GA85822208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program