=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235661182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY ALAN GRIFFIN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2017
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 633D MEDICAL GROUP 77 NEALY AVE
-----------------------------------------------------
City | LANGLEY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-764-1957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 633D MEDICAL GROUP 77 NEALY AVE
-----------------------------------------------------
City | LANGLEY AFB
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 0102208319
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | T6245
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------