=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245273879
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTORINO RODRIGUEZ TELERON JR. M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 06/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 W 3RD AVE
-----------------------------------------------------
City | WILLIAMSON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25661-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-236-5911
-----------------------------------------------------
Fax | 304-236-5942
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 WHISPERING WOODS RD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-2760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-925-6767
-----------------------------------------------------
Fax | 304-925-6767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 12967
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 12967
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------