Provider Demographics
NPI:1053355206
Name:MABE, JEREMY D (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:MABE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1150 STATE HIGHWAY 248
Mailing Address - Street 2:STE. 202
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3758
Mailing Address - Country:US
Mailing Address - Phone:417-348-8964
Mailing Address - Fax:417-336-0275
Practice Address - Street 1:1150 STATE HIGHWAY 248
Practice Address - Street 2:STE. 202
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3758
Practice Address - Country:US
Practice Address - Phone:417-348-8964
Practice Address - Fax:417-336-0275
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2000154576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205804610Medicaid
080174333OtherRAILROAD MEDICARE
14189OtherCOX HEALTH SYSTEMS
144172OtherBCBS
MO208887414Medicaid
462206OtherHEALTHLINK
MOH50303Medicare UPIN
MO205804610Medicaid
080174333OtherRAILROAD MEDICARE
MO208887414Medicaid
006014190Medicare PIN