Provider Demographics
NPI:1376583955
Name:LIDDELL, JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 440 - FITZHUGH-CENTRAL PROFESSIONAL TOWER
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2102
Mailing Address - Country:US
Mailing Address - Phone:214-521-3091
Mailing Address - Fax:214-521-2182
Practice Address - Street 1:4131 N CENTRAL EXPY
Practice Address - Street 2:SUITE 440 - FITZHUGH-CENTRAL PROFESSIONAL TOWER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2102
Practice Address - Country:US
Practice Address - Phone:214-521-3091
Practice Address - Fax:214-521-2182
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ7809207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122110304Medicaid
TX00201JMedicare ID - Type UnspecifiedPHYSICIAN ID