Provider Demographics
NPI:1598750820
Name:DUNN, JACK D (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:DUNN
Suffix:
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 1:2130 MESQUITE AVE UNIT 108
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6897
Mailing Address - Country:US
Mailing Address - Phone:928-854-9433
Mailing Address - Fax:928-854-9443
Practice Address - Street 1:2130 MESQUITE AVE UNIT 108
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6897
Practice Address - Country:US
Practice Address - Phone:928-854-9433
Practice Address - Fax:928-854-9443
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ228842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ300113271OtherRAILROAD MEDICARE
AZ218067Medicaid
AZ03Z317Medicare Oscar/Certification
AZZ129291Medicare PIN
AZZ63272Medicare PIN
AZ300113271OtherRAILROAD MEDICARE
AZ218067Medicaid
AZ031317Medicare Oscar/Certification