1194761973 NPI number — DR. JONATHAN WAXMAN M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194761973 NPI number — DR. JONATHAN WAXMAN M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WAXMAN

Provider First Name:

JONATHAN

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1194761973

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/22/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2995 DREW ST FL 2

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CLEARWATER

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33759-3012

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

727-532-1355

Provider Business Mailing Address Fax Number:

813-635-2613

Provider First Line Business Practice Location Address:

3003 W DR MARTIN LUTHER KING JR BLVD FL 2

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

TAMPA

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33607-6307

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

813-238-0810

Provider Business Practice Location Address Fax Number:

813-238-0811

Provider Enumeration Date:

06/21/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208G00000X , with the licence number:  ME99916 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 208G00000X , with the licence number: 38951 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 209347905 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
• Identifier: 8P057 . This is a "GRP #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 024508200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 09016196 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 3339325 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 3713059 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 4095320 . This is a "INDIVID #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 62-1719735 . This is a "TAX ID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 99676 . This is a "INDIVID #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
• Identifier: 159651001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
• Identifier: 02021708 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 024508200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".