Provider Demographics
NPI:1356427140
Name:STUDEBAKER, JEFFREY BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BRUCE
Last Name:STUDEBAKER
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 1:98 MOSIER PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-1750
Mailing Address - Country:US
Mailing Address - Phone:937-833-4103
Mailing Address - Fax:937-833-3147
Practice Address - Street 1:98 MOSIER PKWY
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-1750
Practice Address - Country:US
Practice Address - Phone:937-833-4103
Practice Address - Fax:937-833-3147
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 044532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000233943OtherANTHEM BC/BS
OH0004570608OtherAETNA
OH0120266OtherUNITED HEALTHCARE
OH0545780Medicaid
OH753061415OtherCORPORATE TAX ID NUMBER
OH0120266OtherUNITED HEALTHCARE
OH753061415OtherCORPORATE TAX ID NUMBER