Provider Demographics
NPI:1568458040
Name:JEFFRIES, MARK S (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:S
Other - Last Name:JEFFRIES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:7740 WASHINGTON VILLAGE DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4056
Mailing Address - Country:US
Mailing Address - Phone:937-297-8999
Mailing Address - Fax:937-433-8030
Practice Address - Street 1:7740 WASHINGTON VILLAGE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4056
Practice Address - Country:US
Practice Address - Phone:937-433-8020
Practice Address - Fax:937-433-8030
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000695157OtherANTHEM BCBS
OH2081938Medicaid
OH2081938Medicaid
OH4038666Medicare PIN
OH000000695157OtherANTHEM BCBS
G83362Medicare UPIN