Provider Demographics
NPI:1992882419
Name:QUALLS, JEFFERSON (MD)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:QUALLS
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 1:4207 N 500 W
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-9251
Mailing Address - Country:US
Mailing Address - Phone:317-695-1241
Mailing Address - Fax:
Practice Address - Street 1:301 HENRY ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1030
Practice Address - Country:US
Practice Address - Phone:317-695-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037759207Q00000X
IN01037759A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100194060Medicaid
IN151560IIIIMedicare PIN
INE24175Medicare UPIN
IN151850CMedicare PIN
IN100194060Medicaid