Provider Demographics
NPI:1639173628
Name:PRIVITERA, JEROME M (DPM)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:M
Last Name:PRIVITERA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8723
Mailing Address - Country:US
Mailing Address - Phone:440-205-5878
Mailing Address - Fax:440-205-5875
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:STE 200
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8723
Practice Address - Country:US
Practice Address - Phone:440-205-5878
Practice Address - Fax:440-205-5875
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH002454213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0799202Medicaid
OH0791214OtherUNITED HEALTHCARE
OH000000242734OtherANTHEM
OH0604655Medicare ID - Type UnspecifiedMENTOR
OH0604656Medicare ID - Type UnspecifiedMADISON
OH0604657Medicare ID - Type UnspecifiedSHAKER
OH0791214OtherUNITED HEALTHCARE
OH0799202Medicaid