Provider Demographics
NPI:1689755472
Name:THAXTON, JEFFREY NORMAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:NORMAN
Last Name:THAXTON
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 1:505 CAPITOL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1204
Mailing Address - Country:US
Mailing Address - Phone:304-925-8949
Mailing Address - Fax:304-925-8953
Practice Address - Street 1:505 CAPITOL ST STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1204
Practice Address - Country:US
Practice Address - Phone:304-925-8949
Practice Address - Fax:304-925-8953
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18001208200000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0046365000Medicaid
CO30225329Medicaid
COG00926Medicare UPIN
CO30225329Medicaid
WVC548418Medicare PIN
WV0046365000Medicaid