Provider Demographics
NPI:1245273879
Name:TELERON, VICTORINO RODRIGUEZ JR (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORINO
Middle Name:RODRIGUEZ
Last Name:TELERON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J. VICTORINO
Other - Middle Name:RODRIGUEZ
Other - Last Name:TELERON
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:250 WHISPERING WOODS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2760
Mailing Address - Country:US
Mailing Address - Phone:304-925-6767
Mailing Address - Fax:304-925-6767
Practice Address - Street 1:116 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3108
Practice Address - Country:US
Practice Address - Phone:304-236-5911
Practice Address - Fax:304-236-5942
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12967207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64080062Medicaid
KY64080062Medicaid
KYD91216Medicare UPIN