Provider Demographics
NPI:1467558544
Name:WAITZMAN, JEFFREY S (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:WAITZMAN
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 1:1875 DEMPSTER ST
Mailing Address - Street 2:STE 265
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-698-0400
Mailing Address - Fax:847-698-0407
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:STE 265
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-698-0400
Practice Address - Fax:847-698-0407
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601976OtherBLUE CROSS BLUE SHIELD
ILC45727Medicare UPIN
IL222090Medicare ID - Type Unspecified