Healthcare Provider Details

I. General information

NPI: 1952329831
Provider Name (Legal Business Name): JACK WILLIAM ROUTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 WILLOW CREEK RD
PRESCOTT AZ
86301-1641
US

IV. Provider business mailing address

PO BOX 11720
PRESCOTT AZ
86304-1720
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-5470
  • Fax: 928-771-5471
Mailing address:
  • Phone: 928-771-5470
  • Fax: 928-771-5471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL3785
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number47343
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: