Provider Demographics
NPI:1497073209
Name:PADALECKI, JEREMY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ALAN
Last Name:PADALECKI
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 1:1100 TERAVISTA XING
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7704
Mailing Address - Country:US
Mailing Address - Phone:210-861-9691
Mailing Address - Fax:
Practice Address - Street 1:1100 TERAVISTA XING
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7704
Practice Address - Country:US
Practice Address - Phone:210-861-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1801207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine