Provider Demographics
NPI:1518900497
Name:JEFFERSON, HENRY C (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:C
Last Name:JEFFERSON
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 1:221 W COLORADO BLVD
Mailing Address - Street 2:PAV II STE 425
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-947-3231
Mailing Address - Fax:214-947-3239
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:PAV II STE 425
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-947-3231
Practice Address - Fax:214-947-3239
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037142903Medicaid
TX037142902Medicaid
TX613647Medicare PIN
8042J0Medicare ID - Type Unspecified
TX037142902Medicaid