Provider Demographics
NPI:1619946670
Name:JEFSON, JERRY A (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:A
Last Name:JEFSON
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1345 UNITY PL
Practice Address - Street 2:SUITE 235
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5760
Practice Address - Country:US
Practice Address - Phone:765-446-5065
Practice Address - Fax:765-446-5170
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048486A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200189100Medicaid
IN000000110556OtherANTHEM PROVIDER NUMBER
IN000000110556OtherANTHEM PROVIDER NUMBER
ING73268Medicare UPIN
IN200189100Medicaid