Individual
DR. JACK W. HIGGINBOTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
500 MARTHA JEFFERSON DR, CHARLOTTESVILLE RADIOLOGY, CHARLOTTESVILLE, VA 22911-4668
(434) 244-4580
(434) 244-4579
Mailing address
PO BOX 197, STATE COLLEGE, PA 16804-0197
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
0101232780
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010140242
—
VA
01
—
P00224457
RRMED
VA
Enumeration date
02/07/2006
Last updated
04/01/2021
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