Healthcare Provider Details

I. General information

NPI: 1073501961
Provider Name (Legal Business Name): JEROME DENNIS SEGEL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 POND RD
WEST TISBURY MA
02575
US

IV. Provider business mailing address

PO BOX 3000/ PMB 3003
WEST TISBURY MA
02575
US

V. Phone/Fax

Practice location:
  • Phone: 508-696-6461
  • Fax: 508-696-6461
Mailing address:
  • Phone: 508-696-6461
  • Fax: 508-696-6461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1701
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: