Provider Demographics
NPI:1073703336
Name:HERSEY, JERRY ROGER (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ROGER
Last Name:HERSEY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 BRIDLE CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1619
Mailing Address - Country:US
Mailing Address - Phone:859-221-4088
Mailing Address - Fax:
Practice Address - Street 1:2517 BRIDLE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1619
Practice Address - Country:US
Practice Address - Phone:859-221-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40615208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVC68501Medicare UPIN