Provider Demographics
NPI:1699955005
Name:EWART, JACKSON M (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:M
Last Name:EWART
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:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-1519
Mailing Address - Country:US
Mailing Address - Phone:843-527-1331
Mailing Address - Fax:843-527-1332
Practice Address - Street 1:903 N FRASER ST # A
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2879
Practice Address - Country:US
Practice Address - Phone:843-527-1331
Practice Address - Fax:843-527-1332
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8834208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7399OtherMEDICARE GROUP PTAN
SC088345Medicaid
SCB923502840Medicare PIN
SC088345Medicaid
SC7399OtherMEDICARE GROUP PTAN