Provider Demographics
NPI:1992781181
Name:PACHECO, JERICK C (MD)
Entity type:Individual
Prefix:
First Name:JERICK
Middle Name:C
Last Name:PACHECO
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 1:528 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1402
Mailing Address - Country:US
Mailing Address - Phone:812-882-4434
Mailing Address - Fax:812-885-6318
Practice Address - Street 1:528 N 1ST ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1402
Practice Address - Country:US
Practice Address - Phone:812-882-4434
Practice Address - Fax:812-885-6318
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081844P208000000X
IN01063831A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200869750AMedicaid
IN200869750AMedicaid
IN441910BBMedicare PIN
IN1224690001Medicare NSC