Provider Demographics
NPI:1477512788
Name:ZUCKERMAN, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:ZUCKERMAN
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 1:101 E OLNEY AVE
Mailing Address - Street 2:400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:KLEIN BUILDING SUITE 331
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-6948
Practice Address - Fax:215-455-1933
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045074E207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012025930002Medicaid
0000605282Medicare ID - Type Unspecified
PA0012025930002Medicaid