Basic Information
| Provider Information | |||||||||
| NPI: | 1174582159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEREZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 SCHOR AVE | ||||||||
| Address2: | |||||||||
| City: | LEONIA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076052237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014610626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3959 BROADWAY | ||||||||
| Address2: | COLUMBIA UNIVERSITY DEPARTMENT PEDIATRICS | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100321559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | 2125441974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | 159415 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00844899 | 05 | NY | MEDICAID |