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General NPI Number Information
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NPI Number | 1982229399
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Entity Type | Individual
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Provider Name | JESSE K LAVERDIERE DO
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Gender | Male
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Dates
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Enumeration Date | 06/11/2020
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Last Update Date | 06/11/2020
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Provider Practice Location Address
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Address Line | 300 E HOSPITAL RD
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City | FORT GORDON
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State | GA
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Zip | 30905
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Country | US
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Telephone | 706-787-5811
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Fax |
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Provider Business Mailing Address
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Address Line | 1021 ALDER WAY APT 121
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City | EVANS
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State | GA
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Zip | 30809-9152
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Country | US
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Telephone | 724-322-6181
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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