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General NPI Number Information
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NPI Number | 1396879086
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Entity Type | Individual
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Provider Name | JEROME THADDEUS MEDLEY M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 120 MEADOWCREST ST SUITE 330
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City | GRETNA
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State | LA
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Zip | 70056-5255
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Country | US
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Telephone | 504-391-7560
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Fax | 504-394-2269
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Provider Business Mailing Address
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Address Line | 4710 OWENS BLVD
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City | NEW ORLEANS
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State | LA
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Zip | 70122-1227
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Country | US
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Telephone | 504-283-0701
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3145R
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License Number State | LA
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