Provider Demographics
NPI:1497739700
Name:WASCHOW, JEANNIE M (DPM)
Entity Type:Individual
Prefix:MRS
First Name:JEANNIE
Middle Name:M
Last Name:WASCHOW
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4792
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:906-779-3144
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4792
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:906-779-3144
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004344213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00384162OtherMEDICARE RAILROAD
T91787Medicare UPIN
IL916400Medicare ID - Type Unspecified
ILP00384162OtherMEDICARE RAILROAD