Provider Demographics
NPI:1750342903
Name:JEFSON, RICHARD T (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:JEFSON
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 1:6565 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-6114
Mailing Address - Country:US
Mailing Address - Phone:269-372-8490
Mailing Address - Fax:269-372-8473
Practice Address - Street 1:6565 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6114
Practice Address - Country:US
Practice Address - Phone:269-372-8490
Practice Address - Fax:269-372-8473
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032154208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4199553Medicaid
MI4199553Medicaid
MIOC96050024024Medicare ID - Type Unspecified