Provider Demographics
NPI:1104966092
Name:JEKOWSKY, ELIOT (MD)
Entity type:Individual
Prefix:
First Name:ELIOT
Middle Name:
Last Name:JEKOWSKY
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 1:4535 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-493-4443
Mailing Address - Fax:
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:330-493-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7004491Medicaid
A56792Medicare UPIN
RI7004491Medicaid