Provider Demographics
NPI:1477750636
Name:REAGAN, JEFFREY MAURICE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MAURICE
Last Name:REAGAN
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 1:4830 HIGHWAY 260 STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5851
Mailing Address - Country:US
Mailing Address - Phone:928-537-8777
Mailing Address - Fax:928-537-1914
Practice Address - Street 1:4830 HIGHWAY 260 STE 103
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5851
Practice Address - Country:US
Practice Address - Phone:928-537-8777
Practice Address - Fax:928-537-1914
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49407207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
471045429OtherEIN