Provider Demographics
NPI:1295828374
Name:DRUMMOND, JERRY WELTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WELTON
Last Name:DRUMMOND
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 1:2514 BERT KOUNS IND LOOP
Mailing Address - Street 2:PHYSICIANS PLAZA #9
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118
Mailing Address - Country:US
Mailing Address - Phone:318-688-5710
Mailing Address - Fax:318-688-5766
Practice Address - Street 1:2514 BERT KOUNS IND LOOP
Practice Address - Street 2:PHYSICIANS PLAZA #9
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-688-5710
Practice Address - Fax:318-688-5766
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA002586FELLOWAMACADEM207W00000X
LAMD03856R207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1176061Medicaid
LA5K350Medicare ID - Type Unspecified
LA1176061Medicaid