Provider Demographics
NPI:1508981689
Name:WACHHOLZ, JEFFREY HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HOWARD
Last Name:WACHHOLZ
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 1:2700 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-8275
Mailing Address - Country:US
Mailing Address - Phone:904-389-3223
Mailing Address - Fax:904-388-5902
Practice Address - Street 1:2700 RIVERSIDE AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-8275
Practice Address - Country:US
Practice Address - Phone:904-389-3223
Practice Address - Fax:904-388-5902
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76268207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
288187OtherAVMED
FL46857OtherBLUE CROSS BLUE SHIELD
FL7137740OtherAETNA
288187OtherAVMED
FLH02209Medicare UPIN