Provider Demographics
NPI:1003039975
Name:DAVIS, JEROME ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:ALFRED
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 COOPER DR
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-5302
Mailing Address - Country:US
Mailing Address - Phone:518-561-4791
Mailing Address - Fax:518-564-2188
Practice Address - Street 1:101 BROAD ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2637
Practice Address - Country:US
Practice Address - Phone:518-564-2187
Practice Address - Fax:518-564-2188
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-100430174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist