Provider Demographics
NPI:1194889543
Name:JEZIOR, JAMES RITCHIE (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RITCHIE
Last Name:JEZIOR
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 1:12041 CREEKBEND DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-5629
Mailing Address - Country:US
Mailing Address - Phone:240-447-0428
Mailing Address - Fax:
Practice Address - Street 1:12255 FAIR LAKES PKWY BLDG 4TH
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3952
Practice Address - Country:US
Practice Address - Phone:703-934-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101059361208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology