Provider Demographics
NPI:1639145634
Name:PRATT, JERRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:PRATT
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 1:5943 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:804-334-2908
Mailing Address - Fax:
Practice Address - Street 1:1722 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1633
Practice Address - Country:US
Practice Address - Phone:269-343-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067178208G00000X
VA0101239206208G00000X
MS17033208G00000X
MI4301100380208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
H56535Medicare UPIN