Individual
DR. JACK VINING
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2700 SE STRATUS AVE, MCMINNVILLE, OR 97128-6255
(503) 472-6131
Mailing address
PO BOX 2065, SEATTLE, WA 98111-2065
(888) 828-3195
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
MD12819
OR
207R00000X
Internal Medicine Physician
MD12819
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0190386
WA L & I
—
05
—
261156
—
OR
05
—
8378382
—
WA
01
—
97128A002
CHAMPUS
—
01
—
D86802
PROVIDENCE
—
01
—
JM9451
PACC
—
01
—
P00333023
RAILROAD MEDICARE
—
05
—
XPY185640
—
CA
Enumeration date
06/14/2006
Last updated
11/28/2007
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