Provider Demographics
NPI:1821069345
Name:DODSON, JACK M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:DODSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-636-5881
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-634-7423
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-08-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO101346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203375613Medicaid
MO203375613Medicaid
MO001012662Medicare PIN