Provider Demographics
NPI:1205822947
Name:METHENY, JEFFRY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:
Last Name:METHENY
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 1:635 ANDERSON RD
Mailing Address - Street 2:#18
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3505
Mailing Address - Country:US
Mailing Address - Phone:530-771-4000
Mailing Address - Fax:530-771-4011
Practice Address - Street 1:635 ANDERSON RD
Practice Address - Street 2:#18
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3505
Practice Address - Country:US
Practice Address - Phone:530-771-4000
Practice Address - Fax:530-771-4011
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
CAG564650174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G564650Medicaid
CA00G564650Medicare ID - Type Unspecified
CA00G564650Medicaid