Provider Demographics
NPI:1679585087
Name:MAXWELL, JACK A (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 FM 2181 STE 100
Mailing Address - Street 2:
Mailing Address - City:HICKORY CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:75065-7636
Mailing Address - Country:US
Mailing Address - Phone:940-497-2204
Mailing Address - Fax:940-321-4977
Practice Address - Street 1:3600 FM 2181 STE 100
Practice Address - Street 2:
Practice Address - City:HICKORY CREEK
Practice Address - State:TX
Practice Address - Zip Code:75065-7636
Practice Address - Country:US
Practice Address - Phone:940-497-2204
Practice Address - Fax:940-321-4977
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9368207Q00000X
TX2869207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124499802Medicaid
TX124499806Medicaid
TX124499806Medicaid
TX86V281Medicare ID - Type Unspecified
TXD97524Medicare UPIN