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General NPI Number Information
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NPI Number | 1144556192
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Entity Type | Organization
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Legal Business Name | DR. JEANETTE JEZICK OD., LLC
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Dates
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Enumeration Date | 10/27/2009
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Last Update Date | 10/27/2009
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Provider Practice Location Address
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Address Line | 1663 ROUTE 12
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City | GALES FERRY
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State | CT
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Zip | 06335-1500
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Country | US
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Telephone | 860-464-1040
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Fax | 860-464-1044
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Provider Business Mailing Address
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Address Line | 1663 ROUTE 12 PO BOX 421
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City | GALES FERRY
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State | CT
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Zip | 06335-1500
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Country | US
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Telephone | 860-464-1040
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Fax | 860-464-1044
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Authorized Official
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Title or Position | MANAGER
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Name | PETER WILBANKS
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Credential |
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Telephone | 860-464-1040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 002353
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License Number State | CT
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