Provider Demographics
NPI:1174523575
Name:NETTLETON, JACK LEE (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:LEE
Last Name:NETTLETON
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 1236
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48480-3236
Mailing Address - Country:US
Mailing Address - Phone:810-342-3800
Mailing Address - Fax:810-342-3784
Practice Address - Street 1:4100 BEECHER RD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3661
Practice Address - Country:US
Practice Address - Phone:810-342-3800
Practice Address - Fax:810-342-3784
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJN0477802085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OM87280002Medicare UPIN
D42501Medicare UPIN
MI4128490Medicare ID - Type Unspecified