Provider Demographics
NPI:1336215516
Name:JETER, CORTLYN (MD)
Entity type:Individual
Prefix:
First Name:CORTLYN
Middle Name:
Last Name:JETER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MAIN ST
Mailing Address - Street 2:ST JOSEPHS HOSPITAL AND MEDICAL CENTER
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07503-2621
Mailing Address - Country:US
Mailing Address - Phone:973-754-2040
Mailing Address - Fax:
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:DEPT OF EMERG MEDICINE
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06215400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8517801Medicaid
NJ054316Medicare PIN
H35402Medicare UPIN
P00424440Medicare PIN
047410Medicare PIN
P00413578Medicare PIN