Basic Information
Provider Information | |||||||||
NPI: | 1558548255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KINGSLEY | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | DEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
Address2: | SC05 | ||||||||
City: | MADERA | ||||||||
State: | CA | ||||||||
PostalCode: | 936368761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5593535700 | ||||||||
FaxNumber: | 5593535708 | ||||||||
Practice Location | |||||||||
Address1: | 825 DELBON AVE | ||||||||
Address2: |   | ||||||||
City: | TURLOCK | ||||||||
State: | CA | ||||||||
PostalCode: | 953822016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2096645065 | ||||||||
FaxNumber: | 2096645067 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2008 | ||||||||
LastUpdateDate: | 04/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 23415 | NE | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | A103298 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | GR0078680 | 01 | CA | GROUP MEDICAID | OTHER |