Provider Demographics
NPI:1316961519
Name:WERTZ, JEFFREY WAYNE
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WAYNE
Last Name:WERTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N INTERSTATE 27
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PLAINVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:79072-3904
Mailing Address - Country:US
Mailing Address - Phone:806-296-7175
Mailing Address - Fax:806-296-0633
Practice Address - Street 1:1001 N INTERSTATE 27
Practice Address - Street 2:SUITE 206
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-3904
Practice Address - Country:US
Practice Address - Phone:806-296-7175
Practice Address - Fax:806-296-0633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX150727156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4465200001Medicare NSC