Provider Demographics
NPI:1316991870
Name:HOMISH, JEROME D (DO)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:D
Last Name:HOMISH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7231 ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-5918
Mailing Address - Country:US
Mailing Address - Phone:678-710-9270
Mailing Address - Fax:478-365-2880
Practice Address - Street 1:7231 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5918
Practice Address - Country:US
Practice Address - Phone:678-710-9270
Practice Address - Fax:470-365-2880
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34-005148207Q00000X
GA899402084A0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1316991870OtherNPI
CE0006OtherRR MEDICARE
OH000000185128OtherUNISON MEDICAID
001714142OtherMOUNTAIN STATE BC/BS
OH0834271OtherMOLINA MEDICAID
000000251326OtherANTHEM BC/BS
WV2003178000Medicaid
OH000000185128OtherUNISON MEDICAID
CE0006OtherRR MEDICARE