Provider Demographics
NPI:1497792584
Name:ENGEL, JEREMY D (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:ENGEL
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-431-0090
Mailing Address - Fax:859-431-3168
Practice Address - Street 1:119 FAIRFIELD AVE
Practice Address - Street 2:SUITE R102
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073
Practice Address - Country:US
Practice Address - Phone:859-431-0090
Practice Address - Fax:859-431-3168
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35995207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2270484Medicaid
KY080159288OtherRAILROAD MEDICARE
KY64013303Medicaid
KYP00839905OtherRAILROAD MEDICARE
KY64013303Medicaid
KYP00839905OtherRAILROAD MEDICARE
KY008580024Medicare PIN