Provider Demographics
NPI:1487609467
Name:FOSNES, JEFFREY CARL (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CARL
Last Name:FOSNES
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 1:220 NORTHCREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-3962
Mailing Address - Country:US
Mailing Address - Phone:615-598-7633
Mailing Address - Fax:931-762-6532
Practice Address - Street 1:220 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3962
Practice Address - Country:US
Practice Address - Phone:615-598-7633
Practice Address - Fax:931-762-6532
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000421Medicaid
TN4103229OtherBLUECROSS BLUESHIELD
TN3000421Medicare ID - Type Unspecified