Healthcare Provider Details

I. General information

NPI: 1275504417
Provider Name (Legal Business Name): JEFFREY ROBERT DUFAULT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E 9TH ST
BONHAM TX
75418-4059
US

IV. Provider business mailing address

6493 E CAMINO GRANDE
ANAHEIM CA
92807-4824
US

V. Phone/Fax

Practice location:
  • Phone: 214-857-4423
  • Fax: 214-857-0506
Mailing address:
  • Phone: 904-891-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: