Provider Demographics
NPI:1659440543
Name:JOHN, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:JOHN
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW STE 203
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2465
Practice Address - Country:US
Practice Address - Phone:540-981-8749
Practice Address - Fax:540-981-9305
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501438207R00000X
UT5210479-1205207RC0000X
VA0101274896207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1659440543Medicaid
NC5902155Medicaid
NC807070OtherPARTNERS MEDICARE
NC140XVOtherBCBS OF NC
NC183494OtherMEDCOST
NC140XVOtherBCBS OF NC
NC183494OtherMEDCOST
UT1659440543Medicaid