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NPI Code Detail

MEDICARE: DR. LISA ELEANOR JEFFERSON D.O.

MEDICARE: DR. LISA ELEANOR JEFFERSON D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician0102050078VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
154208OTHERVAOPTIMA HEALTH
2219614OTHERVAANTHEM BCBS

General Provider Information

NPI Number : 1578502969
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. LISA ELEANOR JEFFERSON D.O.
Provider Business Mailing Address
First Line : 4106 PORTSMOUTH BLVD
Second Line :
City : PORTSMOUTH
State : VA
Zip : 23701-2968
Country : US
Telephone Number : 757-393-1136
Fax Number : 757-698-2499
Provider Business Practice Location Address
First Line : 4106 PORTSMOUTH BLVD
Second Line :
City : PORTSMOUTH
State : VA
Zip : 23701-2968
Country : US
Telephone Number : 757-393-1136
Fax Number : 757-698-2499
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/04/2006
Last Update Date : 12/30/2020

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