Provider Demographics
NPI:1164860961
Name:O'CONNOR, JEREMY M (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:O'CONNOR
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 1:1225 GERARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-8015
Mailing Address - Country:US
Mailing Address - Phone:718-960-2777
Mailing Address - Fax:
Practice Address - Street 1:1225 GERARD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-8015
Practice Address - Country:US
Practice Address - Phone:718-960-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272463207R00000X
CT55573207R00000X
IL125062580207R00000X
NY292463207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT55573OtherCT LICENSE NUMBER