Basic Information
| Provider Information | |||||||||
| NPI: | 1679578363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | GLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 FLEISCHMANN RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508786161 | ||||||||
| FaxNumber: | 8506560200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 FLEISCHMANN RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508786161 | ||||||||
| FaxNumber: | 8506560200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME050710 | GA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | ME080121 | FL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00897498A | 05 | GA | MEDICAID | 258638000 | 05 | FL | MEDICAID |