Provider Demographics
NPI:1588779375
Name:DEARTH, JERRY ALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALVIN
Last Name:DEARTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13410 MAIN ST
Practice Address - Street 2:BOX 340
Practice Address - City:GRABILL
Practice Address - State:IN
Practice Address - Zip Code:46741-2001
Practice Address - Country:US
Practice Address - Phone:260-422-2481
Practice Address - Fax:260-969-3067
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029438A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100055390Medicaid
IN000000595570OtherANTHEM
INP00698419OtherRAILROAD MEDICARE
INP00698419OtherRAILROAD MEDICARE
IN100055390Medicaid
IN259060EMedicare PIN