Provider Demographics
NPI:1184705170
Name:DEBORD, JEFFREY BLAKE (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAKE
Last Name:DEBORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 HEALTH CARE LN
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-4006
Mailing Address - Country:US
Mailing Address - Phone:304-263-6997
Mailing Address - Fax:304-263-8827
Practice Address - Street 1:65 HEALTH CARE LN
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-4006
Practice Address - Country:US
Practice Address - Phone:304-263-6997
Practice Address - Fax:304-263-8827
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0073644000Medicaid
WV0073644000Medicaid
0627723Medicare PIN