1245273879 NPI number — DR. VICTORINO RODRIGUEZ TELERON JR. M.D

Table of content: DR. VICTORINO RODRIGUEZ TELERON JR. M.D (NPI 1245273879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245273879 NPI number — DR. VICTORINO RODRIGUEZ TELERON JR. M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TELERON
Provider First Name:
VICTORINO
Provider Middle Name:
RODRIGUEZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TELERON
Provider Other First Name:
J. VICTORINO
Provider Other Middle Name:
RODRIGUEZ
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1245273879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 WHISPERING WOODS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25304-2760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-925-6767
Provider Business Mailing Address Fax Number:
304-925-6767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 W 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25661-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-236-5911
Provider Business Practice Location Address Fax Number:
304-236-5942
Provider Enumeration Date:
06/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RA0401X , with the licence number:  12967 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 12967 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64080062 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".