Healthcare Provider Details

I. General information

NPI: 1053920504
Provider Name (Legal Business Name): JERRY VARGHESE THUTHIKATTU JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S MAIN ST STE 150
JAMESTOWN NY
14701-6627
US

IV. Provider business mailing address

2400 W VILLARD AVE
MILWAUKEE WI
53209-4901
US

V. Phone/Fax

Practice location:
  • Phone: 716-483-6700
  • Fax: 716-664-7275
Mailing address:
  • Phone: 414-527-8191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77253-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number325117
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: