Provider Demographics
NPI:1700859253
Name:HIGGINBOTHAM, JACK W (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:HIGGINBOTHAM
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:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16804-0197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 MARTHA JEFFERSON DR
Practice Address - Street 2:CHARLOTTESVILLE RADIOLOGY
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4668
Practice Address - Country:US
Practice Address - Phone:434-244-4580
Practice Address - Fax:434-244-4579
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012327802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010140242Medicaid
VAP00224457OtherRRMED
VA010140242Medicaid
VA006943C02Medicare PIN