Provider Demographics
NPI:1386083764
Name:JEFFERS, AVERY (MD)
Entity type:Individual
Prefix:DR
First Name:AVERY
Middle Name:
Last Name:JEFFERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 N 1ST E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1326
Mailing Address - Country:US
Mailing Address - Phone:208-852-3662
Mailing Address - Fax:208-852-1295
Practice Address - Street 1:44 N. 1ST E.
Practice Address - Street 2:ATTN: COLLEEN JENSEN
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1326
Practice Address - Country:US
Practice Address - Phone:208-852-3662
Practice Address - Fax:208-852-1295
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13287207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386083764Medicaid
IDM-13287OtherMEDICAL LICENSE