Provider Demographics
NPI:1871921551
Name:POWELL, JEFFREY DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:POWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 RICHMOND AVE E STE 1
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4652
Practice Address - Country:US
Practice Address - Phone:217-234-7000
Practice Address - Fax:217-234-7011
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04963207R00000X
PAOS019722207R00000X
390200000X
IL036.170637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program