Provider Demographics
NPI:1407297849
Name:KORSH, JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:KORSH
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 1:1219 GUSDORF RD
Mailing Address - Street 2:STE A
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6499
Mailing Address - Country:US
Mailing Address - Phone:575-758-0009
Mailing Address - Fax:575-758-8736
Practice Address - Street 1:41 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9280
Practice Address - Country:US
Practice Address - Phone:802-748-5361
Practice Address - Fax:802-751-8271
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.0014275207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program