Provider Demographics
NPI:1215969860
Name:EBERHART, JACK HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:HENRY
Last Name:EBERHART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST
Mailing Address - Street 2:BLDG D-102
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-327-4429
Mailing Address - Fax:505-327-4420
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG D-102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-327-4429
Practice Address - Fax:505-327-4420
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-223207YX0007X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Not Answered207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR7435Medicaid
NMR7435Medicaid