Provider Demographics
NPI:1669768644
Name:BUEDEFELDT-POLLARD, JESSE TAO (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:TAO
Last Name:BUEDEFELDT-POLLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JESSE
Other - Middle Name:TAO
Other - Last Name:POLLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19640
Mailing Address - Street 2:415 N 9TH ST
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9640
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4912
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 6W100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-4912
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171594207V00000X
IL036140756207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036140756Medicaid
IL036140756Medicaid