Provider Demographics
NPI:1316931702
Name:SHERECK, JON R (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:R
Last Name:SHERECK
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 1:107 E OAK AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-779-7880
Mailing Address - Fax:928-913-8801
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-779-7880
Practice Address - Fax:928-913-8801
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC153955207X00000X
ND7631207X00000X
NE23059207X00000X
AZ59429207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery