Provider Demographics
NPI:1487674453
Name:JEFFCOAT, GERRY L (MD)
Entity Type:Individual
Prefix:
First Name:GERRY
Middle Name:L
Last Name:JEFFCOAT
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:PO BOX 1019
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39703-1019
Mailing Address - Country:US
Mailing Address - Phone:662-328-1862
Mailing Address - Fax:662-328-7597
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:STE 307
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2011
Practice Address - Country:US
Practice Address - Phone:662-328-1862
Practice Address - Fax:662-328-7597
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06422208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015765Medicaid
B66061Medicare UPIN