Provider Demographics
NPI:1578531216
Name:WADSWORTH, JEFFERY TRAD (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:TRAD
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1365A CLIFTON RD NE
Mailing Address - Street 2:ROOM A2303
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-3381
Mailing Address - Fax:404-778-4295
Practice Address - Street 1:1365A CLIFTON RD NE
Practice Address - Street 2:ROOM A2303
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-3381
Practice Address - Fax:404-778-4295
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231639207YX0007X, 207Y00000X, 207YX0901X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006503004Medicaid
NC89064P3Medicaid
VAPAROtherCORVEL/CORCARE
VA294562OtherUHC/MAMSI
VA434684OtherANTHEM
VAPAROtherVA PREMIER HEALTH
VAPAROtherFIRST HEALTH COMMERCIAL
VAPAROtherCIGNA
VAPAROtherUSA MANAGED CARE
NC064P3OtherBC/BS
VAPAROtherVA HEALTH NETWORK
VAPAROtherMULTIPLAN
VA-004OtherTRICARE/CHAMPUS
VA41264OtherSENTARA
VAPAROtherAETNA
VA006503004Medicaid
VAPAROtherFIRST HEALTH COMMERCIAL
VA040016327Medicare PIN