Provider Demographics
NPI:1801835756
Name:KORTMANSKY, JEREMY (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:KORTMANSKY
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 1:19 LUNAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525
Mailing Address - Country:US
Mailing Address - Phone:203-389-7504
Mailing Address - Fax:203-389-8854
Practice Address - Street 1:2080 WHITNEY AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3600
Practice Address - Country:US
Practice Address - Phone:203-407-8002
Practice Address - Fax:203-407-8038
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043345207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001433458Medicaid
CT830000166Medicare PIN
CT001433458Medicaid
G93792Medicare UPIN