Provider Demographics
NPI:1952377897
Name:HUTCHESON, JACK R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:HUTCHESON
Suffix:JR
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 1:2860 JEFFERSON ST SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3320
Mailing Address - Country:US
Mailing Address - Phone:540-520-2284
Mailing Address - Fax:
Practice Address - Street 1:2860 JEFFERSON ST SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-3320
Practice Address - Country:US
Practice Address - Phone:540-520-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030873207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5855195Medicaid
VA830006813OtherMEDICARE RAILROAD
VA900000036Medicare ID - Type Unspecified
B09860Medicare UPIN