Provider Demographics
NPI:1063479384
Name:FRIESEN, JEROLD N (MD)
Entity Type:Individual
Prefix:
First Name:JEROLD
Middle Name:N
Last Name:FRIESEN
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 1:125 E MAXWELL ST
Mailing Address - Street 2:STE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508
Mailing Address - Country:US
Mailing Address - Phone:859-253-0124
Mailing Address - Fax:859-231-8667
Practice Address - Street 1:125 E MAXWELL ST
Practice Address - Street 2:STE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508
Practice Address - Country:US
Practice Address - Phone:859-253-0124
Practice Address - Fax:859-231-8667
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16784207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64167844Medicaid
C64629Medicare UPIN
KY64167844Medicaid