Provider Demographics
NPI:1750919924
Name:JACK, DEBORAH ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANTHONY
Last Name:JACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11013 LAKE VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4272
Mailing Address - Country:US
Mailing Address - Phone:240-281-9613
Mailing Address - Fax:
Practice Address - Street 1:11890 HEALING WAY
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7917
Practice Address - Country:US
Practice Address - Phone:240-637-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2023-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD0097198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program