Provider Demographics
NPI:1538246335
Name:BURKE, JEROME A (OD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:A
Last Name:BURKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S. HAM LANE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-224-5454
Mailing Address - Fax:209-224-8791
Practice Address - Street 1:441 S HAM LN
Practice Address - Street 2:STE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3525
Practice Address - Country:US
Practice Address - Phone:209-224-5454
Practice Address - Fax:209-224-8791
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06004T152W00000X
CAOPT00006004TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABU684ZMedicare PIN
CABU684WMedicare PIN
CABU684YMedicare PIN
CASD0060043Medicare PIN
CAT10199Medicare UPIN
CABU684XMedicare PIN
CABU684VMedicare PIN