Provider Demographics
NPI:1659754190
Name:JEZIOR, MONICA (OD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:JEZIOR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15839 STEVENSON PL
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1886152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist