Healthcare Provider Details

I. General information

NPI: 1003812892
Provider Name (Legal Business Name): JERROLD THOMAS O'ROURKE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/26/2005
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 NEW HAMPSHIRE AVE NW STE 113
WASHINGTON DC
20036-6300
US

IV. Provider business mailing address

1330 NEW HAMPSHIRE AVE NW STE 113
WASHINGTON DC
20036-6300
US

V. Phone/Fax

Practice location:
  • Phone: 202-463-6634
  • Fax: 202-463-6638
Mailing address:
  • Phone: 202-463-6634
  • Fax: 202-463-6638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17238
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: