Provider Demographics
NPI:1740288430
Name:SEWELL, JEFFREY WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:SEWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:WILLIAM
Other - Last Name:VIGIL-SEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-758-7081
Practice Address - Street 1:2131 S MOBBERLY AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-3563
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-212-7689
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37468173000000X
NMMD2007-0623208000000X
TXN7490208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22102701Medicaid
H50321Medicare UPIN