Provider Demographics
NPI:1568452217
Name:WETZORK, EDWARD JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:WETZORK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 ATLANTIC BLVD
Mailing Address - Street 2:SUITE 226
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2936
Mailing Address - Country:US
Mailing Address - Phone:904-338-9400
Mailing Address - Fax:904-338-9404
Practice Address - Street 1:11900 ATLANTIC BLVD
Practice Address - Street 2:SUITE 226
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2936
Practice Address - Country:US
Practice Address - Phone:904-338-9400
Practice Address - Fax:904-338-9404
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8031111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE6583AMedicare ID - Type Unspecified
FLU87987Medicare UPIN