Provider Demographics
NPI:1326740077
Name:JEZULIN, DEREK CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:CHARLES
Last Name:JEZULIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24418 N 37TH LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3344
Mailing Address - Country:US
Mailing Address - Phone:623-695-0029
Mailing Address - Fax:
Practice Address - Street 1:9300 W SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-4844
Practice Address - Country:US
Practice Address - Phone:702-906-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program