Provider Demographics
NPI:1760481766
Name:LETZER, JEFFREY P (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
Last Name:LETZER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1739
Practice Address - Country:US
Practice Address - Phone:833-744-8326
Practice Address - Fax:260-425-6845
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010182207RH0003X
IN02005703A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI123610OtherGREAT LAKES MEDICAID HMO
MI383578337053OtherCARE SOURCE MEDICAID HMO
MI830007320OtherRAIL ROAD MEDICARE
MIJL010182OtherBLUE CROSS BLUE SHIELD MICHIGAN
MI0N89040OtherMEDICARE PLUS BLUE MICHIGAN
MI14662OtherHEALTH PLAN OF MICHIGAN HMO
MI3600159OtherPHP MID MICHIGAN
MIF59303OtherTRICARE
MI4290016Medicaid
MI01008954OtherHEALTHPLUS OF MICHIGAN
MI01008954OtherHEALTHPLUS OF MICHIGAN
MI3600159OtherPHP MID MICHIGAN