Provider Demographics
NPI:1285731752
Name:OLD, JERRY L (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:OLD
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 1:15329 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66219-1262
Mailing Address - Country:US
Mailing Address - Phone:913-599-1125
Mailing Address - Fax:913-599-3554
Practice Address - Street 1:15329 W 95TH ST
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-1262
Practice Address - Country:US
Practice Address - Phone:913-599-1125
Practice Address - Fax:913-599-3554
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-162602081H0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS614032OtherFIRSTGUARD
MO32423014OtherBCBS KANSAS CITY
MO32423014OtherBCBS KANSAS CITY
229B814AMedicare ID - Type Unspecified