Organization
DR. JEANETTE JEZICK OD., LLC
Active
Other names
Eyecare Expressions
Organization subpart
No
Provider details
NPI number
Authorized official
PETER WILBANKS (MANAGER)
(860) 464-1040
Entity
Organization
Contact information
Practice address
1663 ROUTE 12, GALES FERRY, CT 06335-1500
(860) 464-1040
(860) 464-1044
Mailing address
1663 ROUTE 12, PO BOX 421, GALES FERRY, CT 06335-1500
(860) 464-1040
(860) 464-1044
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
002353
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004132429
—
CT
01
—
410000975
MEDICARE ID TYPE UNSPECIFIED PTAN
CT
Enumeration date
10/27/2009
Last updated
10/27/2009
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