Provider Demographics
NPI:1598767113
Name:TABER, JEFFREY DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DAVID
Last Name:TABER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-0187
Mailing Address - Country:US
Mailing Address - Phone:507-831-2550
Mailing Address - Fax:507-831-5528
Practice Address - Street 1:2170 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1287
Practice Address - Country:US
Practice Address - Phone:507-831-2550
Practice Address - Fax:507-831-5528
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN112159OtherUCARE MINNESOTA
MN33246WIOtherBLUE CROSS BLUE SHIELD
MN1506584OtherIA MEDICAID
MNNA3221016530OtherPREFERRED ONE
MN112159OtherUCARE MINNESOTA