Provider Demographics
NPI:1871688275
Name:HOUSE, JERRY L (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:HOUSE
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 1:9002 N MERIDIAN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5350
Mailing Address - Country:US
Mailing Address - Phone:317-848-9505
Mailing Address - Fax:317-848-3623
Practice Address - Street 1:9002 N MERIDIAN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5350
Practice Address - Country:US
Practice Address - Phone:317-848-9505
Practice Address - Fax:317-848-3623
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025675A207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Not Answered207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000078907OtherANTHEM BS
IN086500Medicare ID - Type Unspecified
IN000000078907OtherANTHEM BS