Healthcare Provider Details

I. General information

NPI: 1558512582
Provider Name (Legal Business Name): MARCUS J JEFFERSON O.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 03/12/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 MONTCLAIR RD SUITE 577
BIRMINGHAM AL
35213-1972
US

IV. Provider business mailing address

7445 W WASHINGTON AVE,
LAS VEGAS NV
89128
US

V. Phone/Fax

Practice location:
  • Phone: 205-595-6757
  • Fax: 205-595-0472
Mailing address:
  • Phone: 972-239-8176
  • Fax: 205-595-0472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: