Provider Demographics
NPI:1073689683
Name:BROSSFIELD, JERALYN ELLICE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERALYN
Middle Name:ELLICE
Last Name:BROSSFIELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JERALYN
Other - Middle Name:ELLICE
Other - Last Name:WHITEHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 WATERLOO CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1663
Mailing Address - Country:US
Mailing Address - Phone:760-567-8208
Mailing Address - Fax:760-797-7189
Practice Address - Street 1:72301 COUNTRY CLUB DR STE 104
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-8007
Practice Address - Country:US
Practice Address - Phone:760-573-2761
Practice Address - Fax:760-797-7189
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA064527207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H19388Medicare UPIN
H19388Medicare UPIN