Provider Demographics
NPI:1013948694
Name:CUZZOURT, JEREMY CLIFTON (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:CLIFTON
Last Name:CUZZOURT
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-886-9370
Mailing Address - Fax:740-886-9374
Practice Address - Street 1:98 STATE ST
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8163
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-886-9374
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46380207Y00000X
WV22299207YX0007X
OH35.125222207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00324289OtherRAILROAD MEDICARE
OH2667234Medicaid
WV3810005553Medicaid
KY64127202Medicaid
TN1519145Medicaid
OH2667234Medicaid
TN1519145Medicaid