Basic Information
| Provider Information | |||||||||
| NPI: | 1912903550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFRIES | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 261166 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708261166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372898971 | ||||||||
| FaxNumber: | 3372898970 | ||||||||
| Practice Location | |||||||||
| Address1: | 8595 PICARDY AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257634900 | ||||||||
| FaxNumber: | 2257634938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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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 | 011928 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1670537 | 05 | LA | MEDICAID |