Provider Demographics
NPI:1700878907
Name:PEMBERTON, JAY R (DO)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:R
Last Name:PEMBERTON
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:PO BOX 414965
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-4965
Mailing Address - Country:US
Mailing Address - Phone:913-234-1350
Mailing Address - Fax:
Practice Address - Street 1:201 W R D MIZE RD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2518
Practice Address - Country:US
Practice Address - Phone:816-228-5900
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36771207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO12605135OtherBCBS MO
C51197Medicare UPIN
MON775811Medicare ID - Type Unspecified