Provider Demographics
NPI:1922009414
Name:JEKIELEK, SUSAN ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ANNE
Last Name:JEKIELEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 ALLEN RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1032
Mailing Address - Country:US
Mailing Address - Phone:330-344-3000
Mailing Address - Fax:330-920-6237
Practice Address - Street 1:4302 ALLEN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1032
Practice Address - Country:US
Practice Address - Phone:330-344-3000
Practice Address - Fax:330-920-6237
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2041552Medicaid
OH080145152OtherRAILROAD MEDICARE
OH2041552Medicaid
OH080145152OtherRAILROAD MEDICARE