Provider Demographics
NPI:1427057116
Name:VINE, JACK B (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:VINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8144 WALNUT HILL LN STE 800
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4345
Mailing Address - Country:US
Mailing Address - Phone:214-540-0700
Mailing Address - Fax:214-540-0701
Practice Address - Street 1:8144 WALNUT HILL LN STE 800
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4345
Practice Address - Country:US
Practice Address - Phone:214-540-0700
Practice Address - Fax:214-540-0701
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5735174400000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A57WMedicare ID - Type Unspecified
TXE79968Medicare UPIN