Provider Demographics
NPI:1164462412
Name:GIVENS, JERRY SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:SAMUEL
Last Name:GIVENS
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:525 BRANSON LANDING BLVD
Practice Address - Street 2:FERRELL DUNCAN CLINIC UROLOGY (SUITE 307)
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4500
Practice Address - Country:US
Practice Address - Phone:417-335-7736
Practice Address - Fax:417-334-3038
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR9B09208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164462412Medicaid
MO14360OtherBLUE SHIELD
MO202355806Medicaid
MO431662735OtherTRICARE
AR152379001Medicaid
MO340002079Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MO000005514Medicare ID - Type Unspecified