Provider Demographics
NPI:1922041920
Name:VINING, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:VINING
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 2065
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98111-2065
Mailing Address - Country:US
Mailing Address - Phone:888-828-3195
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-472-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12819207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8378382Medicaid
JM9451OtherPACC
97128A002OtherCHAMPUS
D86802OtherPROVIDENCE
0190386OtherWA L & I
OR261156Medicaid
D86802OtherGROUP HEALTH
CAXPY185640Medicaid
P00333023OtherRAILROAD MEDICARE
JM9451OtherPACC
R00WCQLFEMedicare PIN