Provider Demographics
NPI:1265865471
Name:JEFFREY WISNICKI, M.D., P.A.
Entity type:Organization
Organization Name:JEFFREY WISNICKI, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISNICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-798-1400
Mailing Address - Street 1:13005 SOUTHERN BLVD
Mailing Address - Street 2:SUITE 133
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9206
Mailing Address - Country:US
Mailing Address - Phone:561-798-1400
Mailing Address - Fax:561-798-0255
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:SUITE 133
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-798-1400
Practice Address - Fax:561-798-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 480942086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1154406080OtherNPI FOR INDIVIDUAL PRACTITIONER (JEFFREY L. WISNICKI, M.D.)
61519Medicare UPIN