Provider Demographics
NPI:1609926567
Name:STERN, JERRY PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:PAUL
Last Name:STERN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5552 BIRCH VIEW RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1914
Mailing Address - Country:US
Mailing Address - Phone:262-639-9701
Mailing Address - Fax:262-752-9933
Practice Address - Street 1:1001 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-2500
Practice Address - Country:US
Practice Address - Phone:414-764-3260
Practice Address - Fax:414-764-3260
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38537800Medicaid
WI38537800Medicaid
WIT63425Medicare UPIN