Provider Demographics
NPI:1922369750
Name:JERMAKOWICZ, WALTER JOHN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JOHN
Last Name:JERMAKOWICZ
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4667
Mailing Address - Country:US
Mailing Address - Phone:931-372-7716
Mailing Address - Fax:931-372-7717
Practice Address - Street 1:105 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4667
Practice Address - Country:US
Practice Address - Phone:931-372-7716
Practice Address - Fax:931-372-7717
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN58744207T00000X
FLNOT PROVIDED YET207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ054619Medicaid
TN58744OtherTENNESSEE MEDICAL LICENSE
FLME138513OtherFL STATE LICENSE