Provider Demographics
NPI:1326058629
Name:JEFFERS, TABATHA L
Entity Type:Individual
Prefix:DR
First Name:TABATHA
Middle Name:L
Last Name:JEFFERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 TREASURE LK
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-9017
Mailing Address - Country:US
Mailing Address - Phone:814-375-0460
Mailing Address - Fax:814-375-3472
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-375-6470
Practice Address - Fax:814-375-3472
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-010759-L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001608234OtherHIGHMARK BLUE CROSS
PA0019508010002Medicaid
PA0019508010002Medicaid
PA070271Medicare ID - Type Unspecified