Provider Demographics
NPI:1306924626
Name:THOMAS, JACK M (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8452
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75404-8452
Mailing Address - Country:US
Mailing Address - Phone:903-454-7555
Mailing Address - Fax:903-450-4420
Practice Address - Street 1:4812 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5669
Practice Address - Country:US
Practice Address - Phone:903-454-7555
Practice Address - Fax:903-450-4420
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4718174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F6961Medicare PIN
TX00AK70Medicare PIN
TX6219640001Medicare NSC