Provider Demographics
NPI:1780827022
Name:KERKER, JORDAN T (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:T
Last Name:KERKER
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 1:651 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4938
Mailing Address - Country:US
Mailing Address - Phone:516-681-8822
Mailing Address - Fax:516-681-3332
Practice Address - Street 1:651 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4938
Practice Address - Country:US
Practice Address - Phone:516-681-8822
Practice Address - Fax:516-681-3332
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107283174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06071978OtherBIRTHDATE