Provider Demographics
NPI:1831185222
Name:SCHWARTZ, JERROLD P (MD)
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:P
Last Name:SCHWARTZ
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-763-8008
Mailing Address - Fax:607-763-8019
Practice Address - Street 1:507 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1810
Practice Address - Country:US
Practice Address - Phone:607-763-8008
Practice Address - Fax:607-763-8019
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165144207RA0401X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02313495Medicaid
NYJ400010270Medicare PIN
D06533Medicare UPIN
NY02313495Medicaid