Provider Demographics
NPI:1578706735
Name:HENRY C JEFFERSON MD PLLC
Entity Type:Organization
Organization Name:HENRY C JEFFERSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-942-3295
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:PAV II STE 829
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-942-3295
Mailing Address - Fax:214-946-4491
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:PAV II STE 829
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-942-3295
Practice Address - Fax:214-946-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207721601Medicaid
TX0A3985Medicare PIN