Healthcare Provider Details

I. General information

NPI: 1093371429
Provider Name (Legal Business Name): ERIC MICHAEL JORGENSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 06/21/2025
Certification Date: 06/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 E SHORE DR
ITHACA NY
14850-1026
US

IV. Provider business mailing address

904 E SHORE DR
ITHACA NY
14850-1026
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-6563
  • Fax:
Mailing address:
  • Phone: 607-257-6563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number311096
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: