Basic Information
| Provider Information | |||||||||
| NPI: | 1992774731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIDDENS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5151 N 9TH AVE | ||||||||
| Address2: | ER | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504167000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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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 | 207P00000X | 15687 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | ME68507 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 119219 | 05 | MS | MEDICAID | 274636100 | 05 | FL | MEDICAID |