Provider Demographics
NPI:1265792063
Name:INGRAM, JELANI D (MD)
Entity type:Individual
Prefix:DR
First Name:JELANI
Middle Name:D
Last Name:INGRAM
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:PO BOX 224585
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-4585
Mailing Address - Country:US
Mailing Address - Phone:214-339-2047
Mailing Address - Fax:214-339-2049
Practice Address - Street 1:5201 S WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-1622
Practice Address - Country:US
Practice Address - Phone:214-339-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine