Provider Demographics
NPI:1194725135
Name:YESSENOW, JEFFREY R (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:YESSENOW
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 1:9250 COLUMBIA AVE
Mailing Address - Street 2:STE A2
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-513-1300
Mailing Address - Fax:219-513-2385
Practice Address - Street 1:9250 COLUMBIA AVE
Practice Address - Street 2:STE A2
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-513-1300
Practice Address - Fax:219-513-2385
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030811A207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100214810Medicaid
IN255700AMedicare PIN
IN100214810Medicaid
INB29094Medicare UPIN