Provider Demographics
NPI:1871698993
Name:MCGILLICUDDY, JEFFREY O (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:O
Last Name:MCGILLICUDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 REYNOLDS ROAD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:96020
Mailing Address - Country:US
Mailing Address - Phone:530-258-2826
Mailing Address - Fax:530-258-2802
Practice Address - Street 1:1234 E NORTH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4960
Practice Address - Country:US
Practice Address - Phone:209-647-3101
Practice Address - Fax:209-529-8378
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84589207X00000X
ORMD165006207X00000X
MN58405207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G845890Medicaid
OR500665638Medicaid
OR500665638Medicaid
OR500665638Medicaid