Provider Demographics
NPI:1528020625
Name:JEFFERY, KENT SHEPARD (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:SHEPARD
Last Name:JEFFERY
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 1:1018 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1761
Mailing Address - Country:US
Mailing Address - Phone:651-565-3747
Mailing Address - Fax:
Practice Address - Street 1:1018 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981-1761
Practice Address - Country:US
Practice Address - Phone:507-696-0248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42413207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG84005Medicare UPIN