Provider Demographics
NPI:1508843384
Name:WALCZYK, JEFFREY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:WALCZYK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3385 DEXTER CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3471
Mailing Address - Country:US
Mailing Address - Phone:563-441-5860
Mailing Address - Fax:563-441-5865
Practice Address - Street 1:3385 DEXTER CT
Practice Address - Street 2:SUITE 103
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-441-5860
Practice Address - Fax:563-441-5865
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2014-01-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA26742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508843384Medicaid
IA2042432Medicaid
E08077Medicare UPIN
IA2042432Medicaid
IA719260570Medicare PIN