Healthcare Provider Details

I. General information

NPI: 1659351856
Provider Name (Legal Business Name): JACK H BUMGARDNER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 MAPLE AVE
ROCKY MOUNT VA
24151-1506
US

IV. Provider business mailing address

195 MAPLE AVE
ROCKY MOUNT VA
24151-1506
US

V. Phone/Fax

Practice location:
  • Phone: 540-483-5168
  • Fax: 540-483-5835
Mailing address:
  • Phone: 540-483-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101-021970
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: