Provider Demographics
NPI:1114049566
Name:CLOSE, JEREMY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DAVID
Last Name:CLOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT STREET
Mailing Address - Street 2:SUITE 1402
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4405
Mailing Address - Country:US
Mailing Address - Phone:267-339-7839
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:267-339-3500
Practice Address - Fax:267-339-3761
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT188739207Q00000X
PAMD435873207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102521117Medicaid
PA191229Medicare PIN