Provider Demographics
NPI:1528265097
Name:HITCHCOCK, JEREMY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JOHN
Last Name:HITCHCOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527
Mailing Address - Country:US
Mailing Address - Phone:541-476-6644
Mailing Address - Fax:541-472-5673
Practice Address - Street 1:495 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527
Practice Address - Country:US
Practice Address - Phone:541-476-6644
Practice Address - Fax:541-472-5673
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28543207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025998Medicaid