Provider Demographics
NPI:1285756486
Name:PEDERSON, JEFFREY ALLEN (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-358-9461
Mailing Address - Fax:515-358-9489
Practice Address - Street 1:12493 UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8286
Practice Address - Country:US
Practice Address - Phone:515-358-9461
Practice Address - Fax:515-358-9489
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3976208100000X
MI5101016420208100000X
IADO-03976208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA164196OtherHEALTH ALLIANCE
IA500301OtherCOVENTRY HEALTH CARE
IA164196OtherHEALTH ALLIANCE