Provider Demographics
NPI:1134387129
Name:JEFFRIES, MARY KATHERINE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:JEFFRIES
Suffix:
Gender:F
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:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:VA
Mailing Address - Zip Code:22967
Mailing Address - Country:US
Mailing Address - Phone:434-277-8322
Mailing Address - Fax:
Practice Address - Street 1:1533 BEECH GROVE RD.
Practice Address - Street 2:SUITE #6
Practice Address - City:ROSELAND
Practice Address - State:VA
Practice Address - Zip Code:22967
Practice Address - Country:US
Practice Address - Phone:434-277-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051275171100000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG10409Medicare UPIN