Provider Demographics
NPI:1144208752
Name:JANDA, JEROME W (DO)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:W
Last Name:JANDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6911 C AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1349
Mailing Address - Country:US
Mailing Address - Phone:319-832-1463
Mailing Address - Fax:319-832-4469
Practice Address - Street 1:6911 C AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-1349
Practice Address - Country:US
Practice Address - Phone:319-832-1463
Practice Address - Fax:319-832-4469
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0801168212OtherRR MEDICARE
IA1128744Medicaid
IA2128744Medicaid
IA1144208752Medicaid
IA080080079OtherRR MEDICARE
IA080080079OtherRR MEDICARE
IA2128744Medicaid