Basic Information
| Provider Information | |||||||||
| NPI: | 1356427140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUDEBAKER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 98 MOSIER PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453091750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378334103 | ||||||||
| FaxNumber: | 9378333147 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 MOSIER PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453091750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378334103 | ||||||||
| FaxNumber: | 9378333147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 02/24/2017 | ||||||||
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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 | 35 044532 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000233943 | 01 | OH | ANTHEM BC/BS | OTHER | 0004570608 | 01 | OH | AETNA | OTHER | 0120266 | 01 | OH | UNITED HEALTHCARE | OTHER | 0545780 | 05 | OH | MEDICAID |