Provider Demographics
NPI:1265637573
Name:HANCOCK, JEFFREY D (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:HANCOCK
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 1:1707 W 2175 S
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8565
Mailing Address - Country:US
Mailing Address - Phone:801-725-0280
Mailing Address - Fax:
Practice Address - Street 1:380 WALKER DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1657
Practice Address - Country:US
Practice Address - Phone:208-356-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5755112-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010163793OtherBLUE SHIELD
ID8J950OtherBLUE CROSS
ID807823000Medicaid