Provider Demographics
NPI:1093725111
Name:JETMORE, ALLEN BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:BRUCE
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 1:11111 NALL AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1924
Mailing Address - Country:US
Mailing Address - Phone:913-451-0600
Mailing Address - Fax:913-451-0601
Practice Address - Street 1:11111 NALL AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1924
Practice Address - Country:US
Practice Address - Phone:913-451-0600
Practice Address - Fax:913-451-0601
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0424436174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18198056OtherBCBS OF KANSAS CITY
KSW30000004Medicare PIN
MO18198056OtherBCBS OF KANSAS CITY
KSKA1709001Medicare PIN