Provider Demographics
NPI:1487615407
Name:POWERS, JEROLD L (MD)
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:L
Last Name:POWERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 N 89TH PL
Mailing Address - Street 2:B-121
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6730
Mailing Address - Country:US
Mailing Address - Phone:480-661-0030
Mailing Address - Fax:480-661-9601
Practice Address - Street 1:10752 N 89TH PL
Practice Address - Street 2:B-121
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6730
Practice Address - Country:US
Practice Address - Phone:480-661-0030
Practice Address - Fax:480-661-9601
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ11237207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0027610OtherBLUE CROSS ID
ALE70900Medicare UPIN
AZZMD11237Medicare ID - Type Unspecified