Provider Demographics
NPI:1811206246
Name:MYSIOR, JACEK (MD)
Entity type:Individual
Prefix:DR
First Name:JACEK
Middle Name:
Last Name:MYSIOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:875 ROOSEVELT HWY STE 132
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-4460
Mailing Address - Country:US
Mailing Address - Phone:802-864-7483
Mailing Address - Fax:802-660-4337
Practice Address - Street 1:875 ROOSEVELT HWY STE 132
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-4460
Practice Address - Country:US
Practice Address - Phone:802-864-7483
Practice Address - Fax:802-660-4337
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK117168207RG0100X
VT042.0015577207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology