Provider Demographics
NPI:1790989721
Name:RAYBORN, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:RAYBORN
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 1:9000 N MAIN ST
Mailing Address - Street 2:SUITE 227
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:513-631-0763
Mailing Address - Fax:
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:SUITE 227
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:513-631-0763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57010570390200000X
OH35-091584207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2969640Medicaid
OH57010570OtherMD TRAINING CERTIFICATE
OH57010570OtherMD TRAINING CERTIFICATE