Provider Demographics
NPI:1225081631
Name:SANGIAMO, JERRY STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:STEVEN
Last Name:SANGIAMO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1781
Mailing Address - Country:US
Mailing Address - Phone:610-594-8522
Mailing Address - Fax:610-594-6499
Practice Address - Street 1:317 GORDON DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1201
Practice Address - Country:US
Practice Address - Phone:610-594-8522
Practice Address - Fax:610-594-6499
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005947L111N00000X
NYX004477111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0233920000/043102600OtherPERSONAL CHOICE
PASA028047OtherCOMMERCIAL
PAU72312OtherTRICARE
PA0431026000OtherB/C B/S
PA0431026000OtherB/C B/S
PASA028047OtherCOMMERCIAL