Provider Demographics
NPI:1760412787
Name:TSONG, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:TSONG
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 1:4 DEARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5351
Mailing Address - Country:US
Mailing Address - Phone:203-869-3082
Mailing Address - Fax:203-869-6453
Practice Address - Street 1:4 DEARFIELD DR
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5351
Practice Address - Country:US
Practice Address - Phone:203-869-3082
Practice Address - Fax:203-869-6453
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046608207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
046608OtherCONNECTICARE
3V2537OtherHEALTHNET
CAA95703OtherLICENSE
NY243110OtherMEDICAL LICENSE
663340OtherAETNA
CT046608OtherLICENSE
NJ25MA08270400OtherMEDICAL LICENSE
CTD400000517Medicare PIN