Healthcare Provider Details

I. General information

NPI: 1952308710
Provider Name (Legal Business Name): JEAN PETERS MAKRIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 SOUTH AVE
SOUTH LAKE TAHOE CA
96150-7026
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 530-541-3420
  • Fax: 530-541-8723
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA77127
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA77127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: