Provider Demographics
NPI:1679543995
Name:POWELL, JEFFREY HAIDON (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HAIDON
Last Name:POWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 SOUTH MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468
Mailing Address - Country:US
Mailing Address - Phone:660-582-4022
Mailing Address - Fax:660-582-4038
Practice Address - Street 1:2320 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-3622
Practice Address - Country:US
Practice Address - Phone:660-582-4022
Practice Address - Fax:660-582-4038
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3974310001OtherCIGNA MEDICARE
MO3974310001OtherCIGNA MEDICARE
MOT42499Medicare UPIN