Provider Demographics
NPI:1073501961
Name:SEGEL, JEROME DENNIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:DENNIS
Last Name:SEGEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3000/ PMB 3003
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575
Mailing Address - Country:US
Mailing Address - Phone:508-696-6461
Mailing Address - Fax:508-696-6461
Practice Address - Street 1:20 POND RD
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575
Practice Address - Country:US
Practice Address - Phone:508-696-6461
Practice Address - Fax:508-696-6461
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1701213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0360821Medicaid
MA0360821Medicaid
MA5202050001Medicare NSC
MAY70737Medicare PIN