Provider Demographics
NPI:1790777191
Name:BIRDSONG, JEFF (OD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:BIRDSONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-1665
Mailing Address - Country:US
Mailing Address - Phone:660-882-2444
Mailing Address - Fax:660-882-7976
Practice Address - Street 1:505 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1665
Practice Address - Country:US
Practice Address - Phone:660-882-2444
Practice Address - Fax:660-882-7976
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000092253Medicare ID - Type Unspecified
922535496Medicare PIN
6097790001Medicare NSC
P00453606Medicare PIN
MOV02265Medicare UPIN