MEDICARE: JEFFERSON STREET FAMILY PRACTICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1871690040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERSON STREET FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	1101 W 40TH ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78756-3609
Country	:	US
Telephone Number	:	512-459-4147
Fax Number	:	512-459-9134

Provider Business Practice Location Address
First Line	:	1101 W 40TH ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78756-3609
Country	:	US
Telephone Number	:	512-459-4147
Fax Number	:	512-459-9134

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AJAY KUMAR GUPTA
Credential	:	M.D.
Telephone Number	:	512-458-3185

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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Directions to “JEFFERSON STREET FAMILY PRACTICE ” Practice Location

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