Provider Demographics
NPI:1649272816
Name:FINE, JEFFREY S (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:FINE
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 986
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-0986
Mailing Address - Country:US
Mailing Address - Phone:817-571-8181
Mailing Address - Fax:817-510-1217
Practice Address - Street 1:6750 N MACARTHUR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039
Practice Address - Country:US
Practice Address - Phone:972-253-4205
Practice Address - Fax:972-401-0458
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018765174400000X
TXM6131207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1847469 01Medicaid
LA1934348Medicaid
TX1847469 01Medicaid
LA1934348Medicaid
LAE52930Medicare UPIN