Provider Demographics
NPI:1023154515
Name:PROSSER, JEFFERY ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:ALLEN
Last Name:PROSSER
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:PO BOX 2348
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-2348
Mailing Address - Country:US
Mailing Address - Phone:727-940-7664
Mailing Address - Fax:727-940-7710
Practice Address - Street 1:905 E MARTIN LUTHER KING JR DR STE 390
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4828
Practice Address - Country:US
Practice Address - Phone:727-940-7664
Practice Address - Fax:727-940-7710
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00614755Medicaid
FLHR783AMedicare PIN
FL58770Medicare PIN
FLE95131Medicare UPIN
FL00614755Medicaid