Basic Information
| Provider Information | |||||||||
| NPI: | 1528106630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFRIES | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025882330 | ||||||||
| FaxNumber: | 5025889513 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E. GRAY STREET | ||||||||
| Address2: | SUITE 802 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025882330 | ||||||||
| FaxNumber: | 5025889513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 39805 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 200957710 | 05 | IN | MEDICAID | 7100063520 | 05 | KY | MEDICAID |