1760454284 NPI number — DR. JEFFREY WAYNE BALTZER MD

Table of content: STEVEN JORDAN (NPI 1063495844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760454284 NPI number — DR. JEFFREY WAYNE BALTZER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALTZER
Provider First Name:
JEFFREY
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1760454284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 100275
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32610-0275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-273-7839
Provider Business Mailing Address Fax Number:
352-273-8172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
732 N 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-4442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-365-4575
Provider Business Practice Location Address Fax Number:
352-273-8172
Provider Enumeration Date:
02/07/2006

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: 207ZP0102X , with the licence number:  MD028023E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 188249-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: ME124617 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0017380000001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01927128 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 015363200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 220029208 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CC9269 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: GU039827 . This is a "MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 015363200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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