Provider Demographics
NPI:1639148489
Name:HUNT, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:HUNT
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 1:1820 SHAFFER ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1656
Mailing Address - Country:US
Mailing Address - Phone:269-381-7136
Mailing Address - Fax:269-381-6665
Practice Address - Street 1:1820 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1656
Practice Address - Country:US
Practice Address - Phone:269-381-7136
Practice Address - Fax:269-381-6665
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301022449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1087132Medicaid
MI700C915330OtherBLUE CROSS BLUE SHIELD
MI700C915330OtherBLUE CROSS BLUE SHIELD
MI0C96049003Medicare PIN
MI1087132Medicaid