Provider Demographics
NPI:1194846998
Name:WAIDELICH, JACOB M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:M
Last Name:WAIDELICH
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8340
Practice Address - Fax:920-926-8370
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52040-20207L00000X
MI4301085243390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program