Provider Demographics
NPI:1467400358
Name:ZELEM, JOHN DEMETRO (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DEMETRO
Last Name:ZELEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3354
Mailing Address - Country:US
Mailing Address - Phone:662-720-5131
Mailing Address - Fax:662-720-5135
Practice Address - Street 1:100 HOSPITAL ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3354
Practice Address - Country:US
Practice Address - Phone:662-720-5131
Practice Address - Fax:662-720-5135
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18717208600000X
CT019923208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03331273Medicaid
MS03331273Medicaid