Provider Demographics
NPI:1811080229
Name:JEFFERSON, KEVIN EUGENE (DPM)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:EUGENE
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:DPM
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 55980
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20040-5980
Mailing Address - Country:US
Mailing Address - Phone:202-882-9682
Mailing Address - Fax:202-882-4983
Practice Address - Street 1:6323 GEORGIA AVE NW
Practice Address - Street 2:SUITE 202
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1101
Practice Address - Country:US
Practice Address - Phone:202-882-9682
Practice Address - Fax:202-882-4983
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPO587213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC027002300Medicaid
DCU71147Medicare UPIN
DC000M12M87Medicare PIN
DCG00287Medicare ID - Type UnspecifiedGROUP NUMBER