Provider Demographics
NPI:1396775532
Name:SARGENT, JEFFERY DALE (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:DALE
Last Name:SARGENT
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 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:1990 HOLTON AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3350
Practice Address - Country:US
Practice Address - Phone:276-523-3111
Practice Address - Fax:423-224-3258
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051557207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3009742Medicaid
KY64776792Medicaid
VA015883P50Medicare PIN
TN3009742Medicare PIN
VAVV0387AMedicare PIN
TN3287305Medicare PIN
TN3700107Medicare PIN
TN3009742Medicaid
VAMC10311Medicare PIN
GAP00634207Medicare PIN
VAV V0387BMedicare PIN