Provider Demographics
NPI:1962577676
Name:FELDMAN, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:FELDMAN
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 1:6800 N CALIFORNIA AVE APT 4G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4553
Mailing Address - Country:US
Mailing Address - Phone:773-802-6352
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST STE 519
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-4390
Practice Address - Fax:312-864-4390
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID036-077856207ND0101X
IL036-077856207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery