Provider Demographics
NPI:1174582159
Name:JEREZ, JOSE RAFAEL (MD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:RAFAEL
Last Name:JEREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:143 SCHOR AVE
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-2237
Mailing Address - Country:US
Mailing Address - Phone:201-461-0626
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:COLUMBIA UNIVERSITY DEPARTMENT PEDIATRICS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-304-7250
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1594152080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00844899Medicaid
NYF65599Medicare UPIN
NY00844899Medicaid