Provider Demographics
NPI:1477672863
Name:DEWALL, JEREMY (MD, NREMT-P)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:DEWALL
Suffix:
Gender:M
Credentials:MD, NREMT-P
Other - Prefix:DR
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:DE WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, NREMT-P
Mailing Address - Street 1:PO BOX 173891
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3891
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:16420 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863
Practice Address - Country:US
Practice Address - Phone:719-687-9999
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2365-850207P00000X
CO48580207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30489377Medicaid
CO30489377Medicaid