Provider Demographics
NPI:1063212835
Name:SHOMO, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SHOMO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 S DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3528
Mailing Address - Country:US
Mailing Address - Phone:304-621-5223
Mailing Address - Fax:304-621-5223
Practice Address - Street 1:1123 S DAVIS AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3529
Practice Address - Country:US
Practice Address - Phone:681-378-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist