Provider Demographics
NPI:1568571404
Name:LOVELACE, JERRY LEE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:LOVELACE
Suffix:JR
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 1:1488 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2447
Mailing Address - Country:US
Mailing Address - Phone:901-726-4110
Mailing Address - Fax:901-726-4106
Practice Address - Street 1:1488 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2447
Practice Address - Country:US
Practice Address - Phone:901-726-4110
Practice Address - Fax:901-726-4106
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39486208D00000X
NY226835208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3335622Medicaid
TN3335622Medicare ID - Type Unspecified
NY66S791Medicare ID - Type Unspecified
H80460Medicare UPIN