Healthcare Provider Details

I. General information

NPI: 1821215583
Provider Name (Legal Business Name): JUSTIN JEFFERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST STE 11379
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6143
  • Fax: 410-614-7339
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP00853
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberD74146
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: