Provider Demographics
NPI:1770520173
Name:COLE, JESSE A (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:A
Last Name:COLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S ALABAMA ST STE 6B
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2358
Mailing Address - Country:US
Mailing Address - Phone:406-723-2132
Mailing Address - Fax:406-723-6144
Practice Address - Street 1:401 S ALABAMA ST STE 6B
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2358
Practice Address - Country:US
Practice Address - Phone:406-723-2132
Practice Address - Fax:406-723-6144
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT80112085N0700X, 2085R0204X
MT80112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0022074Medicaid
D16180Medicare UPIN
MT0022074Medicaid