Provider Demographics
NPI:1891228425
Name:JETER, MADELYN FARRELL OLIVER (MD)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:FARRELL OLIVER
Last Name:JETER
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:250 FOUNTAIN CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-263-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57912207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology