Provider Demographics
NPI:1881350155
Name:JEFFERSON, TYVON
Entity type:Individual
Prefix:
First Name:TYVON
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 BROOK PINES DR APT 11111
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-0511
Mailing Address - Country:US
Mailing Address - Phone:843-617-0997
Mailing Address - Fax:
Practice Address - Street 1:237 BROOK PINES DR APT 11111
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-0511
Practice Address - Country:US
Practice Address - Phone:843-617-0997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1239156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician