Healthcare Provider Details

I. General information

NPI: 1063494854
Provider Name (Legal Business Name): JEFFERY PRATER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12579 MAIN ST STE 101
MARTIN KY
41649-7400
US

IV. Provider business mailing address

12579 MAIN ST STE 101
MARTIN KY
41649-7400
US

V. Phone/Fax

Practice location:
  • Phone: 606-285-0681
  • Fax: 606-285-9843
Mailing address:
  • Phone: 606-285-0681
  • Fax: 606-285-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26516
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: