Provider Demographics
NPI:1700853637
Name:JACK, COLIN N (OD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:N
Last Name:JACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 BURLINGTON BEACH RD.
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-0000
Mailing Address - Country:US
Mailing Address - Phone:219-462-0309
Mailing Address - Fax:219-464-4291
Practice Address - Street 1:2101 BURLINGTON BEACH RD.
Practice Address - Street 2:SUITE D
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-0000
Practice Address - Country:US
Practice Address - Phone:219-462-0309
Practice Address - Fax:219-464-4291
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002034152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100208430BMedicaid
IN656510BMedicare ID - Type Unspecified
IN100208430BMedicaid