Provider Demographics
NPI:1720139199
Name:BLAINE, JACK D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:BLAINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:10821 LARKMEADE LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-2704
Mailing Address - Country:US
Mailing Address - Phone:301-983-4493
Mailing Address - Fax:301-983-9379
Practice Address - Street 1:4400 E WEST HWY
Practice Address - Street 2:SUITE 225
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4524
Practice Address - Country:US
Practice Address - Phone:301-983-4493
Practice Address - Fax:301-983-9379
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00045022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD161-967Medicare ID - Type Unspecified