Healthcare Provider Details

I. General information

NPI: 1215969860
Provider Name (Legal Business Name): JACK HENRY EBERHART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG D-102
FARMINGTON NM
87401-8990
US

IV. Provider business mailing address

2300 E 30TH ST BLDG D-102
FARMINGTON NM
87401-8990
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4429
  • Fax: 505-327-4420
Mailing address:
  • Phone: 505-327-4429
  • Fax: 505-327-4420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number97-223
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number97-223
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: