Provider Demographics
NPI:1366888166
Name:JEFFERY A. PROSSER, M.D.
Entity type:Organization
Organization Name:JEFFERY A. PROSSER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PROSSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-943-1684
Mailing Address - Street 1:PO BOX 2348
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34688-2348
Mailing Address - Country:US
Mailing Address - Phone:727-940-7664
Mailing Address - Fax:727-940-7710
Practice Address - Street 1:905 E MLK DR STE 390
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4828
Practice Address - Country:US
Practice Address - Phone:727-940-7664
Practice Address - Fax:727-940-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 81606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL330394OtherMEDICARE PROVIDER #
FL00614755Medicaid
FL58770Medicare PIN
FL330394OtherMEDICARE PROVIDER #
FL00614755Medicaid