Provider Demographics
NPI:1679576706
Name:LAWHEAD, JEFFREY DALE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DALE
Last Name:LAWHEAD
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 1:41120 WASHINGTON ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-9596
Mailing Address - Country:US
Mailing Address - Phone:760-360-3193
Mailing Address - Fax:760-360-3194
Practice Address - Street 1:41120 WASHINGTON ST STE 201
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-9596
Practice Address - Country:US
Practice Address - Phone:760-360-3193
Practice Address - Fax:760-360-3194
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21047207Q00000X
MOR9E18207Q00000X
CAG146704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100545OtherKANSAS BLUE CROSS
MO13829031OtherBCBS KANSAS CITY
KS100545OtherKANSAS BLUE CROSS
KS100545Medicare PIN