Provider Demographics
NPI:1235108390
Name:JEFFERSON, STEPHEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:JEFFERSON
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 1:1535 GULL RD
Mailing Address - Street 2:STE 130
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048
Mailing Address - Country:US
Mailing Address - Phone:269-345-1161
Mailing Address - Fax:269-345-8076
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:STE 130
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048
Practice Address - Country:US
Practice Address - Phone:269-345-1161
Practice Address - Fax:269-345-8076
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISJ040708207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1310080Medicaid
0C96090Medicare ID - Type Unspecified
MI1310080Medicaid