Provider Demographics
NPI:1689682734
Name:IDOL, JEFFREY LEE (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:IDOL
Suffix:
Gender:M
Credentials:DPM
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 59714
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20859-9714
Mailing Address - Country:US
Mailing Address - Phone:301-934-3345
Mailing Address - Fax:301-934-3345
Practice Address - Street 1:515 CHARLES STREET
Practice Address - Street 2:
Practice Address - City:LAPLATA
Practice Address - State:MD
Practice Address - Zip Code:20646
Practice Address - Country:US
Practice Address - Phone:301-934-3345
Practice Address - Fax:301-934-3345
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00992213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU03147Medicare UPIN
MD853L137EMedicare ID - Type Unspecified