Provider Demographics
NPI:1427518885
Name:SO, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 W 32ND ST STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1915
Mailing Address - Country:US
Mailing Address - Phone:877-324-3310
Mailing Address - Fax:
Practice Address - Street 1:1004 W 32ND ST STE 110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1915
Practice Address - Country:US
Practice Address - Phone:877-324-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV76552085R0202X
390200000X
IL125.0746572085R0202X, 207R00000X
TXBP100724832085R0202X
VA01012815102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine