Provider Demographics
NPI:1053920504
Name:JOHN, JERRY VARGHESE THUTHIKATTU (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:VARGHESE THUTHIKATTU
Last Name:JOHN
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 1:2400 W VILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4901
Mailing Address - Country:US
Mailing Address - Phone:414-527-8191
Mailing Address - Fax:
Practice Address - Street 1:15 S MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6627
Practice Address - Country:US
Practice Address - Phone:716-483-6700
Practice Address - Fax:716-664-7275
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77253-20207Q00000X
NY325117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine