Provider Demographics
NPI:1679968788
Name:INGRAM, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:INGRAM
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 1:130 FISHER RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-8132
Mailing Address - Country:US
Mailing Address - Phone:802-371-4100
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD UNIT 1
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-8132
Practice Address - Country:US
Practice Address - Phone:802-371-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.133104207Q00000X
VT042.0016745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0146486Medicaid