Healthcare Provider Details

I. General information

NPI: 1255418893
Provider Name (Legal Business Name): JACK MATTHEW TITUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PENN ST
BALTIMORE MD
21201-1020
US

IV. Provider business mailing address

5720 WESTERN SEA RUN
CLARKSVILLE MD
21029-1665
US

V. Phone/Fax

Practice location:
  • Phone: 410-333-3232
  • Fax: 410-333-3063
Mailing address:
  • Phone: 410-531-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberD0055378
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: