Healthcare Provider Details

I. General information

NPI: 1295837227
Provider Name (Legal Business Name): JERRY JOSEPH SVOBODA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVE SUITE 240
ROCHESTER NY
14626-4296
US

IV. Provider business mailing address

2655 RIDGEWAY AVE SUITE 240
ROCHESTER NY
14626-4296
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7060
  • Fax: 585-723-7325
Mailing address:
  • Phone: 585-723-7060
  • Fax: 585-723-7325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number158142
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: