Provider Demographics
NPI:1689649469
Name:JEFFERSON, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:JEFFERSON
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 1:225 S LAKE AVE
Mailing Address - Street 2:#535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3010
Mailing Address - Country:US
Mailing Address - Phone:626-204-6734
Mailing Address - Fax:626-396-0851
Practice Address - Street 1:1509 WILSON TERRACE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4098
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:818-546-5632
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68903207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G689030Medicaid
CAE64696Medicare UPIN
CA00G689030Medicaid