Provider Demographics
NPI:1437140043
Name:WARREN, JERRY G (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:G
Last Name:WARREN
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 1:220 N RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8009
Mailing Address - Country:US
Mailing Address - Phone:541-672-0477
Mailing Address - Fax:
Practice Address - Street 1:621 SE CASS AVE
Practice Address - Street 2:SUITE 126
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3123
Practice Address - Country:US
Practice Address - Phone:541-580-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD018952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR261735Medicaid
D94325Medicare UPIN
R00WCGFTCMedicare PIN
OR261735Medicaid