Provider Demographics
NPI:1396879086
Name:MEDLEY, JEROME THADDEUS (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:THADDEUS
Last Name:MEDLEY
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 1:4710 OWENS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-1227
Mailing Address - Country:US
Mailing Address - Phone:504-283-0701
Mailing Address - Fax:
Practice Address - Street 1:120 MEADOWCREST ST
Practice Address - Street 2:SUITE 330
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5255
Practice Address - Country:US
Practice Address - Phone:504-391-7560
Practice Address - Fax:504-394-2269
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3145R152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1121335Medicaid
LAB64856Medicare UPIN
LA1121335Medicaid