Provider Demographics
NPI:1821064445
Name:HAMILTON, JACK FREDERICK (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:FREDERICK
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2030 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4120
Mailing Address - Country:US
Mailing Address - Phone:706-738-1925
Mailing Address - Fax:706-738-0705
Practice Address - Street 1:2030 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4120
Practice Address - Country:US
Practice Address - Phone:706-738-1925
Practice Address - Fax:706-738-0705
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000340213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1922914OtherMEDICARE NSC
GA00005904BMedicaid
GA480026649OtherRAILROAD MEDICARE
GA52000361OtherBLUE CROSS BLUE SHIELD
GA48SCBZSOtherMEDICARE
GA480026649OtherRAILROAD MEDICARE