Provider Demographics
NPI:1659351856
Name:BUMGARDNER, JACK H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:H
Last Name:BUMGARDNER
Suffix:JR
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 1:195 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-1506
Mailing Address - Country:US
Mailing Address - Phone:540-483-5168
Mailing Address - Fax:
Practice Address - Street 1:195 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1506
Practice Address - Country:US
Practice Address - Phone:540-483-5168
Practice Address - Fax:540-483-5835
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-021970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005623669Medicaid
VA018144C18Medicare PIN
VA080005667Medicare PIN
VA005623669Medicaid