Provider Demographics
NPI:1154318095
Name:ETHRIDGE, JEFF D (MD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:D
Last Name:ETHRIDGE
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 1:805 KELLY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-3035
Mailing Address - Country:US
Mailing Address - Phone:830-980-1805
Mailing Address - Fax:830-438-5662
Practice Address - Street 1:805 KELLY CREEK RD
Practice Address - Street 2:
Practice Address - City:BULVERDE
Practice Address - State:TX
Practice Address - Zip Code:78163-3035
Practice Address - Country:US
Practice Address - Phone:830-980-1805
Practice Address - Fax:830-438-5662
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6877207Q00000X, 207QH0002X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167684801Medicaid
TX167686808Medicaid
H88154Medicare UPIN