Provider Demographics
NPI:1245228675
Name:SCHOONDYKE, JEFFREY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:SCHOONDYKE
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:PO BOX 5159
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5159
Mailing Address - Country:US
Mailing Address - Phone:423-926-4468
Mailing Address - Fax:423-928-4838
Practice Address - Street 1:701 N STATE OF FRANKLIN RD STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-3645
Practice Address - Country:US
Practice Address - Phone:423-926-4468
Practice Address - Fax:423-928-4838
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36563207RC0000X
VA101237133207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010113652Medicaid
VA007598H87Medicare ID - Type Unspecified
I21800Medicare UPIN