Provider Demographics
NPI:1598797003
Name:JERRY ELLEN OWENSBY, M.D., P.C.
Entity Type:Organization
Organization Name:JERRY ELLEN OWENSBY, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:OWENSBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-610-8183
Mailing Address - Street 1:6242 E ARBOR AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1309
Mailing Address - Country:US
Mailing Address - Phone:480-610-8183
Mailing Address - Fax:480-610-8566
Practice Address - Street 1:6242 E ARBOR AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1309
Practice Address - Country:US
Practice Address - Phone:480-610-8183
Practice Address - Fax:480-610-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0838370OtherBLUE CROSS BLUE SHIELD
AZ1023413OtherCIGNA
AZ1023413OtherCIGNA