Healthcare Provider Details

I. General information

NPI: 1073518288
Provider Name (Legal Business Name): RONALD JC FEJERAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1442 N BROAD ST SUITE 7
TAZEWELL TN
37879-4361
US

IV. Provider business mailing address

PO BOX 959 ATTN: CREDENTIALING
NEW TAZEWELL TN
37824-0959
US

V. Phone/Fax

Practice location:
  • Phone: 423-626-1931
  • Fax: 423-626-1948
Mailing address:
  • Phone: 423-626-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number999
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0999
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: