Provider Demographics
NPI:1215939467
Name:JETMORE, DAVID LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LOUIS
Last Name:JETMORE
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 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-983-3127
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1434 CHESTER BLVD.
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1919
Practice Address - Country:US
Practice Address - Phone:765-966-1600
Practice Address - Fax:765-962-9641
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023140A174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000841132OtherANTHEM
OH0544192Medicaid
IN100256310Medicaid
OH0833301Medicare PIN
OH0544192Medicaid
IN100256310Medicaid