Provider Demographics
NPI:1033317417
Name:JERNIGAN, PAUL ARAM (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ARAM
Last Name:JERNIGAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 W 62ND ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-3538
Mailing Address - Country:US
Mailing Address - Phone:913-709-8482
Mailing Address - Fax:
Practice Address - Street 1:5150 ROE BLVD
Practice Address - Street 2:
Practice Address - City:ROELAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66205-2359
Practice Address - Country:US
Practice Address - Phone:913-403-9013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSU92026Medicare UPIN