MEDICARE: JERRY ELLEN OWENSBY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	23843	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1023413	OTHER	AZ	CIGNA PROVIDER NUMBER
2	AZ0838370	OTHER	AZ	BCBS PROVIDER NUMBER
3	2Z1452	OTHER	AZ	HEALTHNET PROVIDER NUMBER

General Provider Information

NPI Number	:	1871524132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY ELLEN OWENSBY M.D.

Provider Business Mailing Address
First Line	:	871 CORONADO CENTER DR STE 200
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-3977
Country	:	US
Telephone Number	:	702-803-0034
Fax Number	:

Provider Business Practice Location Address
First Line	:	871 CORONADO CENTER DR STE 200
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-3977
Country	:	US
Telephone Number	:	702-803-0034
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	06/14/2023

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