Provider Demographics
NPI:1528202462
Name:EMMONS, JERRY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ROBERT
Last Name:EMMONS
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 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-313-4631
Mailing Address - Fax:
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-313-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258495207PE0004X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03341462Medicaid
NYJ400046365/GRPBA0017Medicare PIN
NYJ400046363/GRP70008AMedicare PIN