Provider Demographics
NPI:1134181688
Name:JALAZO, JESSE BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:BRIAN
Last Name:JALAZO
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 1:1002 SUSHRUTA DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-0913
Mailing Address - Fax:304-267-2917
Practice Address - Street 1:1002 SUSHRUTA DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-0913
Practice Address - Fax:304-267-2917
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4403390OtherAETNA
WV0084592000Medicaid
WVJA0563581Medicare ID - Type Unspecified
WV0084592000Medicaid