Provider Demographics
NPI:1699770446
Name:LONDON, JEREMY E (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:E
Last Name:LONDON
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 1:602 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4913
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-7850
Practice Address - Street 1:11700 MERCY BLVD.
Practice Address - Street 2:PLAZA D SUITE A
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419
Practice Address - Country:US
Practice Address - Phone:912-819-0500
Practice Address - Fax:912-819-0501
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-07-21
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
GA050403208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000921401EMedicaid
GA000921401HMedicaid
GA000921401FMedicaid
GA000921401GMedicaid
SCG22407Medicaid
GA202I335892Medicare PIN
GA000921401FMedicaid
GA000921401FMedicaid