Provider Demographics
NPI:1306846407
Name:FENWICK, JEFFREY RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
Last Name:FENWICK
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 1:960 E WALNUT LAWN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7506
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:960 E WALNUT LAWN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7506
Practice Address - Country:US
Practice Address - Phone:417-875-3600
Practice Address - Fax:417-875-3612
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15294207Y00000X
MO2005041177207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC152998Medicaid
MO200282606Medicaid
MO938564838Medicare PIN