Provider Demographics
NPI:1740573567
Name:BURNELL, JEFFREY SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:BURNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 BEAVER CREEK CIR
Mailing Address - Street 2:# 110
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1745
Mailing Address - Country:US
Mailing Address - Phone:419-891-6210
Mailing Address - Fax:419-893-3232
Practice Address - Street 1:660 BEAVER CREEK CIR
Practice Address - Street 2:# 110
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1745
Practice Address - Country:US
Practice Address - Phone:419-891-6210
Practice Address - Fax:419-893-3232
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-011393207QS0010X
OH34011393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH335891Medicare PIN