Provider Demographics
NPI:1073680336
Name:NOAH, JEROLD ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROLD
Middle Name:ANTHONY
Last Name:NOAH
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 1:5641 STANFORD ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4244
Mailing Address - Country:US
Mailing Address - Phone:805-654-0271
Mailing Address - Fax:
Practice Address - Street 1:825 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-1309
Practice Address - Country:US
Practice Address - Phone:805-933-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI04193Medicare UPIN
CAWA83320CMedicare PIN