Provider Demographics
NPI:1548226558
Name:JERLES, MATTHEW L (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:JERLES
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 1:540 HEMLCOK ST.
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31032
Mailing Address - Country:US
Mailing Address - Phone:478-743-8953
Mailing Address - Fax:
Practice Address - Street 1:540 HEMLCOK ST.
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-743-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38262207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7444269-003OtherCIGNA
GA481258OtherB/S B/S
GA00645411BMedicaid
GA7444269-003OtherCIGNA
GAF86847Medicare UPIN