Provider Demographics
NPI:1194761973
Name:WAXMAN, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:WAXMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD FL 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-238-0810
Practice Address - Fax:813-238-0811
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99916208G00000X
TN38951208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209347905Medicaid
AR8P057OtherGRP #
FL024508200Medicaid
MS09016196Medicaid
TN3339325Medicaid
TN3713059Medicaid
TN4095320OtherINDIVID #
TN62-1719735OtherTAX ID
AR99676OtherINDIVID #
AR159651001Medicaid
MS02021708Medicaid
AR8P057OtherGRP #
TN3713059Medicare ID - Type UnspecifiedGRP #
AR99676OtherINDIVID #
TNP00160980Medicare ID - Type UnspecifiedRR INDIVID #
TN3339325Medicaid
FLAG453ZMedicare PIN