Provider Demographics
NPI:1124099957
Name:WAIDNER, JOHN W (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:WAIDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2627 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4712
Mailing Address - Country:US
Mailing Address - Phone:904-308-7372
Mailing Address - Fax:904-308-6909
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4712
Practice Address - Country:US
Practice Address - Phone:904-308-7372
Practice Address - Fax:904-308-6909
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2009-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME 0062495208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2595028-00Medicaid
FL2595028-00Medicaid