Provider Demographics
NPI:1871657171
Name:MOTHERSHEAD, JERRY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:MOTHERSHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:707 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1622
Mailing Address - Country:US
Mailing Address - Phone:757-627-3876
Mailing Address - Fax:757-627-3876
Practice Address - Street 1:707 WESTOVER AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1622
Practice Address - Country:US
Practice Address - Phone:757-627-3876
Practice Address - Fax:757-627-3876
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101040838207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine