Provider Demographics
NPI:1275506362
Name:POKORNY, JEFFREY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:POKORNY
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 1:1141 N ROAD ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3354
Mailing Address - Country:US
Mailing Address - Phone:252-335-2293
Mailing Address - Fax:252-331-2387
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:SUITE K
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-335-2293
Practice Address - Fax:252-331-2387
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4188432086S0122X
NC2009-01310208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019044240002Medicaid
NY02285858Medicaid
H70125Medicare UPIN
PA062184N9FMedicare ID - Type UnspecifiedINDIVIDUAL
NY02285858Medicaid