Healthcare Provider Details

I. General information

NPI: 1386639516
Provider Name (Legal Business Name): JEFFERY LYNN ALLYN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 03/01/2022
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S MAIN ST
RANDOLPH VT
05060-1381
US

IV. Provider business mailing address

44 S MAIN ST
RANDOLPH VT
05060-1381
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-7000
  • Fax:
Mailing address:
  • Phone: 802-728-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-48629
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042.0015727
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: