Provider Demographics
NPI:1093711012
Name:WALZEL, JACK LEE (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LEE
Last Name:WALZEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1022
Mailing Address - Country:US
Mailing Address - Phone:512-302-1210
Mailing Address - Fax:512-451-9752
Practice Address - Street 1:3705 MEDICAL PKWY STE 250
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1022
Practice Address - Country:US
Practice Address - Phone:512-302-1210
Practice Address - Fax:512-451-9752
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8490208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX020013348Medicare PIN
TX81A068Medicare PIN
E18118Medicare UPIN
TX102121401Medicaid
TX4337816OtherAETNA