Healthcare Provider Details

I. General information

NPI: 1528003852
Provider Name (Legal Business Name): JEFFREY GLEN HUXFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 8TH AVE NE
DEMOTTE IN
46310-9108
US

IV. Provider business mailing address

PO BOX 20
DEMOTTE IN
46310-0020
US

V. Phone/Fax

Practice location:
  • Phone: 219-987-3581
  • Fax: 219-987-7137
Mailing address:
  • Phone: 219-987-3581
  • Fax: 219-987-7137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01061998A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: