Provider Demographics
NPI:1780842708
Name:HARRELL, JERRY DEWITT JR (MD DTMH)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DEWITT
Last Name:HARRELL
Suffix:JR
Gender:M
Credentials:MD DTMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WHITEFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2230
Mailing Address - Country:US
Mailing Address - Phone:912-638-8237
Mailing Address - Fax:
Practice Address - Street 1:411 WHITEFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2230
Practice Address - Country:US
Practice Address - Phone:912-638-8237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028926L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology