Provider Demographics
NPI:1629073440
Name:JEFFRIES, BRUCE (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:OH
Mailing Address - Zip Code:44672-2005
Mailing Address - Country:US
Mailing Address - Phone:330-938-2647
Mailing Address - Fax:
Practice Address - Street 1:331 S 15TH ST
Practice Address - Street 2:PO 278
Practice Address - City:SEBRING
Practice Address - State:OH
Practice Address - Zip Code:44672-2005
Practice Address - Country:US
Practice Address - Phone:330-938-2647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5269/T2177152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2370394Medicaid
6670040001Medicare NSC
OH4073195Medicare ID - Type Unspecified