Provider Demographics
NPI:1619976966
Name:SPITZBERG, JACK W (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:SPITZBERG
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 1:8440 WALNUT HILL LN STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3879
Mailing Address - Country:US
Mailing Address - Phone:214-369-3613
Mailing Address - Fax:214-369-6042
Practice Address - Street 1:8440 WALNUT HILL LN STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3879
Practice Address - Country:US
Practice Address - Phone:214-369-3613
Practice Address - Fax:214-369-6042
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4085207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116656301Medicaid
TX110044853OtherRAILROAD
TX060036467OtherRAILROAD
TX116656303Medicaid
TXP00044329OtherRAILROAD
TX80A132OtherBCBS
TX116656301Medicaid
TXP00044329OtherRAILROAD
TX110044853OtherRAILROAD