Basic Information
| Provider Information | |||||||||
| NPI: | 1144291758 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LORD | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 4012 N 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504444777 | ||||||||
| FaxNumber: | 8504343387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101049921 | VA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME92672 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 23796300 | 05 | FL | MEDICAID |