Basic Information
| Provider Information | |||||||||
| NPI: | 1770570855 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID J JEWELL APMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61950 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705961950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372615151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 WILSON ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379810305 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | JEWELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MD | ||||||||
| AuthorizedOfficialTelephone: | 3379810305 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1369837 | 05 | LA | MEDICAID |