Provider Demographics
NPI:1629039607
Name:MEINCKE-REZA, JEFFREY W (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:W
Last Name:MEINCKE-REZA
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 1:835 PARKSIDE ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-8505
Mailing Address - Country:US
Mailing Address - Phone:920-745-3500
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:835 PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-8505
Practice Address - Country:US
Practice Address - Phone:920-745-3500
Practice Address - Fax:920-745-7930
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41012207X00000X
TXK6887207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00007908OtherRAILROAD MEDICARE
TX0036JTOtherBLUE CROSS BLUE SHIELD
OK200039200AMedicaid
TX3101855OtherAETNA
TX045592503Medicaid
TX3000OtherNEIC
TX3000OtherNEIC
TXP00007908OtherRAILROAD MEDICARE
OK200039200AMedicaid
TXBM6107076OtherDEA