Provider Demographics
NPI:1215935705
Name:WHETZEL, JERRY WARREN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WARREN
Last Name:WHETZEL
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 W VOTAW ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1302
Practice Address - Country:US
Practice Address - Phone:260-726-7616
Practice Address - Fax:260-726-8165
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051865207Q00000X
IN01051865A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000308400OtherANTHEM
8659OtherPHP
IN200249490Medicaid
IN401730FMedicare PIN
8659OtherPHP