Basic Information
Provider Information | |||||||||
NPI: | 1528110780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEFFERSON | ||||||||
FirstName: | LATRISE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 RIVER RD | ||||||||
Address2: | STE 100 | ||||||||
City: | CONSHOHOCKEN | ||||||||
State: | PA | ||||||||
PostalCode: | 194282439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003553818 | ||||||||
FaxNumber: | 6108342862 | ||||||||
Practice Location | |||||||||
Address1: | 110 IRVING ST NW | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200102976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2028779696 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2007 | ||||||||
LastUpdateDate: | 11/27/2007 | ||||||||
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 | 207P00000X | MD034722 | DC | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.