Provider Demographics
NPI:1851728141
Name:WANNARES, JEFFREY
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:WANNARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6415 REFLECTION DR APT 206
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3167
Mailing Address - Country:US
Mailing Address - Phone:508-898-0986
Mailing Address - Fax:
Practice Address - Street 1:8554 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9558
Practice Address - Country:US
Practice Address - Phone:619-698-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-01040208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1851728141Medicaid
NC19RFYOtherBCBS OF NC
NCNCY8940322OtherMEDICARE