Provider Demographics
NPI:1871524132
Name:OWENSBY, JERRY ELLEN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ELLEN
Last Name:OWENSBY
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 1:871 CORONADO CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3977
Mailing Address - Country:US
Mailing Address - Phone:702-803-0034
Mailing Address - Fax:
Practice Address - Street 1:871 CORONADO CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3977
Practice Address - Country:US
Practice Address - Phone:702-803-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1023413OtherCIGNA PROVIDER NUMBER
AZAZ0838370OtherBCBS PROVIDER NUMBER
AZ2Z1452OtherHEALTHNET PROVIDER NUMBER
AZG09743Medicare UPIN
AZ1023413OtherCIGNA PROVIDER NUMBER