Provider Demographics
NPI:1891726535
Name:JEDAMSKI, WALDTRAUT (MD)
Entity Type:Individual
Prefix:
First Name:WALDTRAUT
Middle Name:
Last Name:JEDAMSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27412 ENTERPRISE CIR W STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-4801
Mailing Address - Country:US
Mailing Address - Phone:951-694-6367
Mailing Address - Fax:951-694-1428
Practice Address - Street 1:27412 ENTERPRISE CIR W STE 102
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4801
Practice Address - Country:US
Practice Address - Phone:951-694-6367
Practice Address - Fax:951-694-1428
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39074208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA47694Medicare UPIN