Provider Demographics
NPI:1699874495
Name:JEFFCOAT, LYDIA R (MD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:R
Last Name:JEFFCOAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WALLACE BASHAW WAY
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-3875
Mailing Address - Country:US
Mailing Address - Phone:978-465-0635
Mailing Address - Fax:978-465-0941
Practice Address - Street 1:1 WALLACE BASHAW WAY
Practice Address - Street 2:SUITE 2003
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3875
Practice Address - Country:US
Practice Address - Phone:978-465-0635
Practice Address - Fax:978-465-0941
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA80924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110055616AMedicaid
MAJ31149Medicare ID - Type Unspecified
MA110055616AMedicaid