Provider Demographics
NPI:1851326813
Name:ANDERSON, JEFFREY ROSS (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROSS
Last Name:ANDERSON
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 1:300 HIGHLAND BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4600
Mailing Address - Country:US
Mailing Address - Phone:601-442-4343
Mailing Address - Fax:601-442-4311
Practice Address - Street 1:300 HIGHLAND BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4792
Practice Address - Country:US
Practice Address - Phone:601-442-4343
Practice Address - Fax:601-442-4311
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08487007Medicaid
MS080003909Medicare ID - Type UnspecifiedMEDICARE
MS512I080293Medicare UPIN
MS08487007Medicaid