Provider Demographics
NPI:1760595342
Name:NORTHUP, JEFFERY CARLETON (DO)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:CARLETON
Last Name:NORTHUP
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 1:5171 CUB LAKE ROAD
Mailing Address - Street 2:BLDG B SUITE 210
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901
Mailing Address - Country:US
Mailing Address - Phone:800-344-8299
Mailing Address - Fax:928-537-4437
Practice Address - Street 1:5171 CUB LAKE ROAD
Practice Address - Street 2:BLDG B SUITE 210
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901
Practice Address - Country:US
Practice Address - Phone:800-344-8299
Practice Address - Fax:928-537-4437
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ227654-02Medicaid
AZD01447AMedicare ID - Type Unspecified
AZ227654-02Medicaid