Healthcare Provider Details

I. General information

NPI: 1295230514
Provider Name (Legal Business Name): JEROD ALAN BUELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MADISON AVE FL 3
ELMIRA NY
14901-3219
US

IV. Provider business mailing address

571 SAINT JOSEPHS BLVD FL 2
ELMIRA NY
14901-3230
US

V. Phone/Fax

Practice location:
  • Phone: 607-734-1581
  • Fax: 607-734-0972
Mailing address:
  • Phone: 607-271-2050
  • Fax: 607-873-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number312893
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: