Provider Demographics
NPI:1609845403
Name:JAMES, JACK DONALD (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DONALD
Last Name:JAMES
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 1:1380 MILSTEAD AVE NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3864
Mailing Address - Country:US
Mailing Address - Phone:770-760-7007
Mailing Address - Fax:770-760-7611
Practice Address - Street 1:1380 MILSTEAD AVE NE
Practice Address - Street 2:SUITE B
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3864
Practice Address - Country:US
Practice Address - Phone:770-760-7007
Practice Address - Fax:770-760-7611
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015479174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00155284DMedicaid
GA00155284DMedicaid