Provider Demographics
NPI:1518999598
Name:LONDON, JEROME R (DO)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:R
Last Name:LONDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:R
Other - Last Name:LONDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:19 OLD MILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4697
Mailing Address - Country:US
Mailing Address - Phone:856-545-4355
Mailing Address - Fax:
Practice Address - Street 1:19 OLD MILL DRIVE
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4697
Practice Address - Country:US
Practice Address - Phone:856-545-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02755900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA124224QGXMedicare ID - Type Unspecified
PAE06300Medicare UPIN