Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0203X | Pediatric Critical Care Doctor | G2400 | TX |
Y | 2080P0214X | Pediatric Pulmonologist | G2400 | TX |
NPI | 1083794341 |
---|---|
Provider Name | Larry Jefferson |
First Address | Houston, TX 77030-2303 |
Second Address | Houston, TX 77030-2316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2006 |
Last Update Date | 17/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
134850003 | (05) | TX |
E80318 | (02) |