Provider Demographics
NPI:1104899186
Name:FEDERMAN, JAY L (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:L
Last Name:FEDERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4060 BUTLER PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1560
Mailing Address - Country:US
Mailing Address - Phone:800-331-6634
Mailing Address - Fax:267-420-1360
Practice Address - Street 1:100 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1108
Practice Address - Country:US
Practice Address - Phone:800-331-6634
Practice Address - Fax:267-420-1360
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009276E207W00000X, 207W00000X
NJMA04747900207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000751607-0002Medicaid
NJ2176602Medicaid
NJ2176602Medicaid
PA018360EV6Medicare PIN
PAD71012Medicare UPIN
PA018360EV6Medicare PIN
NJ707676AHDMedicare PIN
DE1952552630OtherRETINOVITREOUSE ASSOCIATES LTD TYPE 2 NPI# IN DE
PA018360EV6Medicare PIN
NJ707676AHDMedicare PIN
PA018360FVUMedicare PIN
PA180028119Medicare PIN
NJ180038462Medicare PIN