Provider Demographics
NPI:1235152943
Name:JEFFERSON, TED H (DO)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:H
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:DOB#3 SUITE 602
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:DOB#3 SUITE 602
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-442-2449
Practice Address - Fax:270-442-6628
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02703207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000200948OtherANTHEM
KY64032436Medicaid
KYP00159684Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KY64032436Medicaid
KYH15613Medicare UPIN