Provider Demographics
NPI:1679578363
Name:FORD, JERRY GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:GLEN
Last Name:FORD
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 1:2020 FLEISCHMANN RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4599
Mailing Address - Country:US
Mailing Address - Phone:850-878-6161
Mailing Address - Fax:850-656-0200
Practice Address - Street 1:2020 FLEISCHMANN RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4599
Practice Address - Country:US
Practice Address - Phone:850-878-6161
Practice Address - Fax:850-656-0200
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAME050710207W00000X
FLME080121207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00897498AMedicaid
FL258638000Medicaid
F93813Medicare UPIN
FLE3902ZMedicare ID - Type Unspecified
GA18BDGCCMedicare ID - Type Unspecified