Provider Demographics
NPI:1639131774
Name:IRWIN, JERI PETTY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERI
Middle Name:PETTY
Last Name:IRWIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 DUPONT SQ S
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4615
Mailing Address - Country:US
Mailing Address - Phone:502-584-0128
Mailing Address - Fax:502-584-0149
Practice Address - Street 1:1108 DUPONT CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4804
Practice Address - Country:US
Practice Address - Phone:502-897-0139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY197912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64197916Medicaid
KY1065702Medicare PIN
KY64197916Medicaid