Provider Demographics
NPI:1912134685
Name:JEFFERY, KYLE
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:JEFFERY
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 1:925 E MCDOWELL RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2502
Mailing Address - Country:US
Mailing Address - Phone:602-239-2282
Mailing Address - Fax:
Practice Address - Street 1:945 W HOSPITAL DR STE 4
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4230
Practice Address - Country:US
Practice Address - Phone:435-613-7874
Practice Address - Fax:435-637-1808
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368163-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty