Provider Demographics
NPI:1780788356
Name:CALLAWAY, JERRY LESTER (MD)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LESTER
Last Name:CALLAWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2512 SAMARITAN COURT
Mailing Address - Street 2:SUITE M
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124
Mailing Address - Country:US
Mailing Address - Phone:408-358-3715
Mailing Address - Fax:408-356-9189
Practice Address - Street 1:2512 SAMARITAN COURT
Practice Address - Street 2:SUITE M
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124
Practice Address - Country:US
Practice Address - Phone:408-358-3715
Practice Address - Fax:408-356-9189
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA25401207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A254010Medicaid
A24422Medicare UPIN
CA00A254010Medicare ID - Type Unspecified