Provider Demographics
NPI:1417042714
Name:ADAMS, JERRY W (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:ADAMS
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:PO BOX 88193
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208
Mailing Address - Country:US
Mailing Address - Phone:317-926-8839
Mailing Address - Fax:317-926-8853
Practice Address - Street 1:3351 NORTH MERIDIAN STREET
Practice Address - Street 2:STE 202
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208
Practice Address - Country:US
Practice Address - Phone:317-926-8839
Practice Address - Fax:317-926-8853
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028871208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100084010CMedicaid
IN100084010CMedicaid
C24345Medicare UPIN