Provider Demographics
NPI:1437192739
Name:PATTON, JACK T (MD)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:T
Last Name:PATTON
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 1:199 W SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4102
Mailing Address - Country:US
Mailing Address - Phone:559-225-4706
Mailing Address - Fax:559-225-4710
Practice Address - Street 1:199 W SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4102
Practice Address - Country:US
Practice Address - Phone:559-225-4706
Practice Address - Fax:559-225-4710
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G158270Medicaid
CA00G158270Medicaid
A39631Medicare UPIN