Provider Demographics
NPI:1457353492
Name:CONSAMUS, JACK FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:FRANCIS
Last Name:CONSAMUS
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 1:1814 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2038
Mailing Address - Country:US
Mailing Address - Phone:563-324-0471
Mailing Address - Fax:563-324-2948
Practice Address - Street 1:1814 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2038
Practice Address - Country:US
Practice Address - Phone:563-324-0471
Practice Address - Fax:563-324-2948
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22075207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2080846Medicaid
IAI10942Medicare ID - Type Unspecified
IA2080846Medicaid