Individual
JERRY L OLD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
15329 W 95TH ST, LENEXA, KS 66219-1262
(913) 599-1125
(913) 599-3554
Mailing address
15329 W 95TH ST, LENEXA, KS 66219-1262
(913) 599-1125
(913) 599-3554
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
04-16260
KS
2081H0002X
Hospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
Primary
04-16260
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
32423014
BCBS KANSAS CITY
MO
01
—
614032
FIRSTGUARD
KS
Enumeration date
09/19/2006
Last updated
09/11/2025
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