1972507556 NPI number — JEFFREY D WASSERMAN DO

Table of content: JEFFREY D WASSERMAN DO (NPI 1972507556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972507556 NPI number — JEFFREY D WASSERMAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WASSERMAN
Provider First Name:
JEFFREY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972507556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2804 REMINGTON GREEN CIR STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-385-4494
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1249 STRONG ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32353-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-875-9500
Provider Business Practice Location Address Fax Number:
850-627-2786
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS3951 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: OS3951 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 047973000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 99388 . This is a "MEDICARE GROUP ASSOCIATED PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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