Provider Demographics
NPI:1578620100
Name:WAYDA, JEFFERY DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:DAVID
Last Name:WAYDA
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 1:62 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9806
Mailing Address - Country:US
Mailing Address - Phone:630-554-1848
Mailing Address - Fax:630-554-1292
Practice Address - Street 1:62 S MADISON ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9806
Practice Address - Country:US
Practice Address - Phone:630-554-1848
Practice Address - Fax:630-554-1292
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL624940Medicare PIN
U63438Medicare UPIN