Provider Demographics
NPI:1366557738
Name:FERTIG, JESSE JACOB (OD)
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:JACOB
Last Name:FERTIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12430 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1501
Mailing Address - Country:US
Mailing Address - Phone:718-261-2344
Mailing Address - Fax:
Practice Address - Street 1:12430 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1501
Practice Address - Country:US
Practice Address - Phone:718-261-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3702-35152W00000X
IL346002045152W00000X
FLTPOP68152W00000X
IA105426152W00000X
VA0618002935152W00000X
NYTUV007355152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400007318Medicare PIN
U97411Medicare UPIN