Provider Demographics
NPI:1801900220
Name:BLUE, JEFFREY G (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:G
Last Name:BLUE
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 1:221 E HACIENDA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6625
Mailing Address - Country:US
Mailing Address - Phone:408-404-4700
Mailing Address - Fax:408-404-4701
Practice Address - Street 1:221 E HACIENDA AVE STE C
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-6625
Practice Address - Country:US
Practice Address - Phone:408-404-4700
Practice Address - Fax:408-404-4701
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA060369207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A603690Medicare ID - Type Unspecified
CAH04676Medicare UPIN