Basic Information
| Provider Information | |||||||||
| NPI: | 1326121286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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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 | 207Q00000X | M4593 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD00025241 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31254 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1326121286 | 01 | ID | HEALTHY CONNECTIONS | OTHER | 1326121286 | 01 | ID | REGENCE BLUESHIELD OF IDAHO | OTHER | 1007806 | 05 | WA | MEDICAID | 1326121286 | 05 | ID | MEDICAID | 80094289 | 01 | ID | RAILROAD MEDICARE | OTHER | DF540 | 01 | ID | BLUE CROSS | OTHER | 1119637 | 01 | ID | DMERC | OTHER |