Basic Information
| Provider Information | |||||||||
| NPI: | 1679779052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEWELL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882015010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756274200 | ||||||||
| FaxNumber: | 5756274212 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MILITARY HEIGHTS PL | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882016407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756279500 | ||||||||
| FaxNumber: | 5756279535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RS20070331 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2010-0710 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 92953875 | 05 | NM | MEDICAID |