Individual
JEFFREY RICHARD FENWICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
960 E WALNUT LAWN ST, SUITE 102, SPRINGFIELD, MO 65807-7506
(417) 875-3600
(417) 875-3612
Mailing address
960 E WALNUT LAWN ST, SUITE 102, SPRINGFIELD, MO 65807-7506
(417) 875-3000
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
15294
SC
207Y00000X
Otolaryngology Physician
Primary
2005041177
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
152998
—
SC
05
—
200282606
—
MO
Enumeration date
07/29/2005
Last updated
12/27/2018
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