Provider Demographics
NPI:1255321014
Name:DREW, JACK M (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:DREW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5901 TECHNOLOGY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6013
Mailing Address - Country:US
Mailing Address - Phone:719-578-1162
Mailing Address - Fax:719-578-1462
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5853
Practice Address - Fax:719-365-1048
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00518242085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24275069Medicaid
CO388111YLQ8Medicare PIN
CO24275069Medicaid