Provider Demographics
NPI:1144336231
Name:TRACHTENBERG, JERRY MILTON (DO)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:MILTON
Last Name:TRACHTENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JEROME
Other - Middle Name:MILTON
Other - Last Name:TRACHTENBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7044 LYNFORD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1714
Mailing Address - Country:US
Mailing Address - Phone:215-725-6713
Mailing Address - Fax:
Practice Address - Street 1:WORKHEALTH KNIGHTS & RED LION RDS
Practice Address - Street 2:SUITE 206-MOB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114
Practice Address - Country:US
Practice Address - Phone:215-612-4836
Practice Address - Fax:215-612-4904
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S005352-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E55431Medicare UPIN