Provider Demographics
NPI:1871669614
Name:JEZIORO, JOHN RICHARD (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:JEZIORO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2158
Mailing Address - Country:US
Mailing Address - Phone:304-363-8890
Mailing Address - Fax:304-363-8902
Practice Address - Street 1:1565 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2158
Practice Address - Country:US
Practice Address - Phone:304-363-8890
Practice Address - Fax:304-363-8902
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000342746OtherBCBS
WV7600047000Medicaid
WVJE0839572Medicare ID - Type Unspecified
WV7600047000Medicaid