Provider Demographics
NPI:1952307498
Name:HUBBARD, JERRY LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEROY
Last Name:HUBBARD
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 1:875 OAK ST SE
Mailing Address - Street 2:STE 5060
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3987
Mailing Address - Country:US
Mailing Address - Phone:503-399-1386
Mailing Address - Fax:503-399-1182
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:STE 5060
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3987
Practice Address - Country:US
Practice Address - Phone:503-399-1386
Practice Address - Fax:503-399-1182
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11848207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR118968Medicaid
ORR014WFBZFBMedicare PIN
OR118968Medicaid