Provider Demographics
NPI:1760405443
Name:JEWELL, JAMES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:JEWELL
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 1:4001 KRESGE WAY
Mailing Address - Street 2:236
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4640
Mailing Address - Country:US
Mailing Address - Phone:502-895-6588
Mailing Address - Fax:502-893-6587
Practice Address - Street 1:4001 KRESGE WAY
Practice Address - Street 2:236
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-895-6588
Practice Address - Fax:502-893-6587
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64203250Medicaid
KY64203250Medicaid
KY1339701Medicare ID - Type Unspecified