Provider Demographics
NPI:1932111283
Name:STREET, JERRY (MD, PA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:STREET
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 BUSINESS CENTER DR STE 202
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-2741
Mailing Address - Country:US
Mailing Address - Phone:713-461-5808
Mailing Address - Fax:713-973-0853
Practice Address - Street 1:1140 BUSINESS CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-2741
Practice Address - Country:US
Practice Address - Phone:713-461-5808
Practice Address - Fax:713-973-0853
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5763207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033376701Medicaid
TX033376701Medicaid
TX00FQ37Medicare ID - Type Unspecified