Provider Demographics
NPI:1750478558
Name:FORD, JEFFREY EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EDWARD
Last Name:FORD
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 1:14406 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1448
Mailing Address - Country:US
Mailing Address - Phone:360-481-6001
Mailing Address - Fax:360-571-3108
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-418-6001
Practice Address - Fax:360-571-3108
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032604207Q00000X
ORMD18943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8161945Medicaid
WA8161945Medicaid