Provider Demographics
NPI:1437291655
Name:WARREN, JAMIE ALLEN (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:ALLEN
Last Name:WARREN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CANNONS LN STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2164
Mailing Address - Country:US
Mailing Address - Phone:502-454-4885
Mailing Address - Fax:502-452-1926
Practice Address - Street 1:2800 CANNONS LN STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205
Practice Address - Country:US
Practice Address - Phone:502-454-4885
Practice Address - Fax:502-452-1926
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8142122300000X, 1223S0112X
KY44040204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100152170Medicaid
KYP01500679OtherRAILROAD MEDICARE
KY7100154720Medicaid
IN201055760Medicaid
KYP01500679OtherRAILROAD MEDICARE