Basic Information
| Provider Information | |||||||||
| NPI: | 1144279977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMERTON | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 FACTORY ST | ||||||||
| Address2: | PO BOX 91 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157824207 | ||||||||
| FaxNumber: | 3157828699 | ||||||||
| Practice Location | |||||||||
| Address1: | 428 WASHINGTON ST | ||||||||
| Address2: | STE 4 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136014832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157884880 | ||||||||
| FaxNumber: | 3157884896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 227318 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00354315 | 05 | NY | MEDICAID |