Provider Demographics
NPI:1215928189
Name:ISAACSON, WAYNE (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:ISAACSON
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 1:4035 EVANS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9308
Mailing Address - Country:US
Mailing Address - Phone:239-939-7375
Mailing Address - Fax:239-939-5105
Practice Address - Street 1:4035 EVANS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9308
Practice Address - Country:US
Practice Address - Phone:239-939-7375
Practice Address - Fax:239-939-5105
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71098207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253173900Medicaid
32138OtherBLUE CROSS BLUE SHIELD
F81545Medicare UPIN
32138OtherBLUE CROSS BLUE SHIELD