Healthcare Provider Details

I. General information

NPI: 1568400901
Provider Name (Legal Business Name): JEFFERSON MED-PEDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E 5TH AVE
RANSON WV
25438-1613
US

IV. Provider business mailing address

207 E 5TH AVE
RANSON WV
25438-1613
US

V. Phone/Fax

Practice location:
  • Phone: 304-279-1372
  • Fax: 304-728-3623
Mailing address:
  • Phone: 304-279-1372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16223
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16223
License Number StateWV

VIII. Authorized Official

Name: DR. VIKRAM DAYAL
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 304-279-1372