Provider Demographics
NPI:1891767257
Name:PICCIRILLO, JEFFREY LYNN (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LYNN
Last Name:PICCIRILLO
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 1:1114 WEST ST
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-1646
Mailing Address - Country:US
Mailing Address - Phone:641-236-7846
Mailing Address - Fax:877-480-3023
Practice Address - Street 1:1114 WEST ST
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1646
Practice Address - Country:US
Practice Address - Phone:641-236-7846
Practice Address - Fax:877-480-3023
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3594207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13387Medicare ID - Type Unspecified