Provider Demographics
NPI:1083766919
Name:POPHAM, JEFFRY VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:VINCENT
Last Name:POPHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:929 LOOP 332
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-0037
Mailing Address - Country:US
Mailing Address - Phone:512-778-5500
Mailing Address - Fax:512-778-5500
Practice Address - Street 1:929 LOOP 332
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-0037
Practice Address - Country:US
Practice Address - Phone:512-778-5500
Practice Address - Fax:512-778-5500
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4366111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601658OtherBLUE CROSS BLUE SHIELD #
TX601658OtherBLUE CROSS BLUE SHIELD #
TX601658Medicare PIN