Basic Information
| Provider Information | |||||||||
| NPI: | 1164415832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2670 CRAIN HWY | ||||||||
| Address2: | STE 204 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206012816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019348811 | ||||||||
| FaxNumber: | 3019349321 | ||||||||
| Practice Location | |||||||||
| Address1: | 2670 CRAIN HWY | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206012806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013749300 | ||||||||
| FaxNumber: | 3013749469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0054044 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | KCJ9LI | 01 | MD | BLUE CROSS | OTHER | G338 0001 | 01 | DC | BLUE CROSS | OTHER | 0405399 | 01 | MD | UNITED HEALTHCARE | OTHER | 2121023 | 01 | MD | MAMSI ALLIANCE | OTHER | 332602100 | 05 | MD | MEDICAID | DB5669 | 01 | MD | RAILROAD RETIREMENT | OTHER | 100431 | 01 | MD | PRIORITY PARTNERS | OTHER |