Provider Demographics
NPI:1154361343
Name:DENVER, JACK DAVID (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:DAVID
Last Name:DENVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 SOUTHLAKE PARK
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3352
Mailing Address - Country:US
Mailing Address - Phone:205-874-9663
Mailing Address - Fax:205-874-9667
Practice Address - Street 1:1500 SOUTHLAKE PARK
Practice Address - Street 2:SUITE 150
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3352
Practice Address - Country:US
Practice Address - Phone:205-874-9663
Practice Address - Fax:205-874-9667
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00017495208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000085235Medicaid
AL051085235OtherBLUE CROSS BLUE SHIELD
AL11492407OtherCAQH ID NUMBER
AL609603500OtherDEPT OF LABOR
AL102I259373Medicare PIN
ALF60498Medicare UPIN
AL609603500OtherDEPT OF LABOR
AL000085235Medicare ID - Type Unspecified