Provider Demographics
NPI:1861768780
Name:CAMACHO, JENNY ELYSE (MD)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:ELYSE
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:ELYSE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4199 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630
Mailing Address - Country:US
Mailing Address - Phone:812-842-4200
Mailing Address - Fax:
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-0001
Practice Address - Country:US
Practice Address - Phone:812-842-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01082540A2080N0001X
NMMD2015-0035208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300028022Medicaid