Basic Information
| Provider Information | |||||||||
| NPI: | 1104899699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 E UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852138436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808928400 | ||||||||
| FaxNumber: | 4808929533 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 N CAMINO MERCADO | ||||||||
| Address2: | STE 1 | ||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852225759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204269224 | ||||||||
| FaxNumber: | 5204261554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 940 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.