Provider Demographics
NPI:1225057805
Name:PLUMMER, JON KIRK (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:KIRK
Last Name:PLUMMER
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 1:190 COUNTY ROAD 45650
Mailing Address - Street 2:
Mailing Address - City:BLOSSOM
Mailing Address - State:TX
Mailing Address - Zip Code:75416-3524
Mailing Address - Country:US
Mailing Address - Phone:903-784-4627
Mailing Address - Fax:
Practice Address - Street 1:190 COUNTY ROAD 45650
Practice Address - Street 2:
Practice Address - City:BLOSSOM
Practice Address - State:TX
Practice Address - Zip Code:75416-3524
Practice Address - Country:US
Practice Address - Phone:903-784-4627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B5724OtherINDIVIDUAL BLUE CROSS
TX080190728OtherINDIVIDUAL RAILROAD MC
TX118179OtherSUPERIOR
TX130517907Medicaid
TX144831802OtherGROUP TEXAS HEALTH STEPS
TX5473079OtherAETNA
TX080190728OtherINDIVIDUAL RAILROAD MC
TX118179OtherSUPERIOR