Healthcare Provider Details

I. General information

NPI: 1043705288
Provider Name (Legal Business Name): MICHAEL JOSEPH JERJOS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W GIRARD AVE STE 5
PHILADELPHIA PA
19123-1660
US

IV. Provider business mailing address

217 GARRISONVILLE RD
STAFFORD VA
22554-1527
US

V. Phone/Fax

Practice location:
  • Phone: 215-554-6222
  • Fax:
Mailing address:
  • Phone: 540-658-6983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004135
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003080
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: