Provider Demographics
NPI:1144556192
Name:DR. JEANETTE JEZICK OD., LLC
Entity type:Organization
Organization Name:DR. JEANETTE JEZICK OD., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-464-1040
Mailing Address - Street 1:1663 ROUTE 12
Mailing Address - Street 2:PO BOX 421
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-1500
Mailing Address - Country:US
Mailing Address - Phone:860-464-1040
Mailing Address - Fax:860-464-1044
Practice Address - Street 1:1663 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1500
Practice Address - Country:US
Practice Address - Phone:860-464-1040
Practice Address - Fax:860-464-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410000975OtherMEDICARE ID TYPE UNSPECIFIED PTAN
CT004132429Medicaid
CTU46251Medicare UPIN