Basic Information
| Provider Information | |||||||||
| NPI: | 1922295237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINDA M. JEFFERSON, MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2670 CRAIN HWY | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206012806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013749300 | ||||||||
| FaxNumber: | 3013749469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2670 CRAIN HWY | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206012806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013749300 | ||||||||
| FaxNumber: | 3013749469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 06/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | JEFFERSON | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3013749300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0054004 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 332602100 | 05 | MD | MEDICAID |