Healthcare Provider Details

I. General information

NPI: 1497915730
Provider Name (Legal Business Name): JEREMY R ETZKORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SPRUCE STREET 2 MALONEY BLDG
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3600 SPRUCE STREET 2 MALONEY BLDG
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2737
  • Fax:
Mailing address:
  • Phone: 215-662-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN122223
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME110688
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME110688
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME110688
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD451783
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: