Provider Demographics
NPI:1740248152
Name:WESTFALL, JACKIE W (DO)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:W
Last Name:WESTFALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 E INTERNATIONAL SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-2744
Mailing Address - Country:US
Mailing Address - Phone:386-736-1105
Mailing Address - Fax:386-734-1443
Practice Address - Street 1:2370 E INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2744
Practice Address - Country:US
Practice Address - Phone:386-736-1105
Practice Address - Fax:386-734-1443
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5855207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80464OtherBCBS PROVIDER NUMBER
FL054261000Medicaid
FL054261000Medicaid
FL80464Medicare PIN
FL80464SMedicare PIN
AL059187328OtherBCBS PROVIDER NUMBER
FLP00324083Medicare PIN
FL80464TMedicare PIN