Provider Demographics
NPI:1518223338
Name:JERRY L. CALLAWAY M.D., INC
Entity Type:Organization
Organization Name:JERRY L. CALLAWAY M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-358-3715
Mailing Address - Street 1:2512 SAMARITAN CT
Mailing Address - Street 2:SUITE M
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4002
Mailing Address - Country:US
Mailing Address - Phone:408-358-3715
Mailing Address - Fax:408-356-9189
Practice Address - Street 1:2512 SAMARITAN CT
Practice Address - Street 2:SUITE M.
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4002
Practice Address - Country:US
Practice Address - Phone:408-358-3715
Practice Address - Fax:408-356-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24422Medicare UPIN