Provider Demographics
NPI:1922064047
Name:WHITAKER, JACK H (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:H
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:1410 TUSCULUM BLVD.,
Practice Address - Street 2:SUITE 1500
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745
Practice Address - Country:US
Practice Address - Phone:423-638-2270
Practice Address - Fax:423-928-0219
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-02-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN20931207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN01S2OtherJOHN DEERE
TN3078282Medicaid
TN4082722OtherBCBS
TN3078282Medicaid