Provider Demographics
NPI:1730113374
Name:JEFFERSON, VIRGIL SINATRA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:SINATRA
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 1:412 JORDAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2309
Mailing Address - Country:US
Mailing Address - Phone:228-377-6495
Mailing Address - Fax:228-377-9170
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534-2519
Practice Address - Country:US
Practice Address - Phone:228-377-6495
Practice Address - Fax:228-377-9170
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045275171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider