Provider Demographics
NPI:1134108210
Name:FEARON-JEWELL, MARIE B (DO)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:B
Last Name:FEARON-JEWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:B
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:298 OAK CREST LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:WV
Mailing Address - Zip Code:24925-9729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:WV
Practice Address - Zip Code:24983
Practice Address - Country:US
Practice Address - Phone:304-772-3064
Practice Address - Fax:304-772-5671
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201186207Q00000X
WV1749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00466094OtherRAILROAD PTAN
WV001717979OtherBLUE CROSS BLUE SHIELD
VA345878OtherANTHEM
VA010038251Medicaid
WVP00466094OtherRAILROAD PTAN
VA00V567J05Medicare ID - Type Unspecified
WV001717979OtherBLUE CROSS BLUE SHIELD
VAH36993Medicare UPIN