Healthcare Provider Details

I. General information

NPI: 1154986503
Provider Name (Legal Business Name): KENNETH BRIAN JEZIERSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODS RD
VALHALLA NY
10595-1530
US

IV. Provider business mailing address

703 MAIN ST
PATERSON NJ
07503-2621
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7000
  • Fax:
Mailing address:
  • Phone: 973-754-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number323459
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA11891800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: