Provider Demographics
NPI:1295959757
Name:JACK L. EARLE, M.D., P.A.
Entity type:Organization
Organization Name:JACK L. EARLE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:EARLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-656-6721
Mailing Address - Street 1:8715 VILLAGE DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5405
Mailing Address - Country:US
Mailing Address - Phone:210-656-6721
Mailing Address - Fax:210-655-4309
Practice Address - Street 1:8715 VILLAGE DR
Practice Address - Street 2:SUITE 600
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5405
Practice Address - Country:US
Practice Address - Phone:210-656-6721
Practice Address - Fax:210-655-4309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00TT68OtherMEDICAR ID #
TX0658080001Medicare NSC