Provider Demographics
NPI:1952329831
Name:ROUTSON, JACK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:WILLIAM
Last Name:ROUTSON
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 11720
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1720
Mailing Address - Country:US
Mailing Address - Phone:928-771-5470
Mailing Address - Fax:928-771-5471
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:928-771-5470
Practice Address - Fax:928-771-5471
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTL3785207Q00000X
AZ47343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYH63397Medicare UPIN