Provider Demographics
NPI:1164457412
Name:HEDRICK, JERRY LEO (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEO
Last Name:HEDRICK
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 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:500 VONDERBURG DRIVE
Practice Address - Street 2:STE 115W
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5969
Practice Address - Country:US
Practice Address - Phone:813-685-0306
Practice Address - Fax:813-651-1026
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38730207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070000215OtherRAILROAD MEDICARE
FL101936200Medicaid
FL30425OtherBLUE CROSS BLUE SHIELD
FLK8018Medicare ID - Type Unspecified
FL30425OtherBLUE CROSS BLUE SHIELD