Healthcare Provider Details

I. General information

NPI: 1285731752
Provider Name (Legal Business Name): JERRY L OLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15329 W 95TH ST
LENEXA KS
66219-1262
US

IV. Provider business mailing address

15329 W 95TH ST
LENEXA KS
66219-1262
US

V. Phone/Fax

Practice location:
  • Phone: 913-599-1125
  • Fax: 913-599-3554
Mailing address:
  • Phone: 913-599-1125
  • Fax: 913-599-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-16260
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number04-16260
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: