Provider Demographics
NPI:1386900116
Name:GHABLY, JACK GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:GEORGE
Last Name:GHABLY
Suffix:
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:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:7001 SIGNAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2453
Practice Address - Country:US
Practice Address - Phone:505-856-2735
Practice Address - Fax:505-856-2749
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-0386207K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM584457AC7EOtherMEDICARE PTAN
NM82000727Medicaid