Provider Demographics
NPI:1427168376
Name:ROMERO, JESSICA VANESSA (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:VANESSA
Last Name:ROMERO
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 1:3381 PHILLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1560
Mailing Address - Country:US
Mailing Address - Phone:843-577-7011
Mailing Address - Fax:
Practice Address - Street 1:3381 PHILLIS BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1560
Practice Address - Country:US
Practice Address - Phone:843-577-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15539208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3953OtherPMC M MEDICARE CHOICE
PR0022929ROOtherTRIPLE S
PR7380082OtherHUMANA
PRM000611OtherMENONITA
PR3953OtherPMC M MEDICARE CHOICE
PR002-2929Medicare ID - Type Unspecified