Provider Demographics
NPI:1033111331
Name:HOLMES, JED D (MD)
Entity type:Individual
Prefix:
First Name:JED
Middle Name:D
Last Name:HOLMES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7111 E 21ST STREET N
Mailing Address - Street 2:SUITE A
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206
Mailing Address - Country:US
Mailing Address - Phone:316-684-2851
Mailing Address - Fax:316-686-7338
Practice Address - Street 1:7111 E 21ST STREET N
Practice Address - Street 2:SUITE A
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-684-2851
Practice Address - Fax:316-686-7338
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-18241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS80186351OtherRAILROAD MEDICARE
KS110718OtherBLUE CROSS GROUP
KS101601OtherBLUE CROSS INDIVIDUAL
KS100084320BMedicaid
KS101601OtherCHAMPUS
IA621541OtherFIRSTGUARD
KS100416440AMedicaid
KS110718OtherBLUE CROSS GROUP
KS110718Medicare ID - Type UnspecifiedGROUP
KS101601OtherBLUE CROSS INDIVIDUAL