Provider Demographics
NPI:1972543676
Name:WACHS, JEFFREY A (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:WACHS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:GLENBROOK
Mailing Address - State:NV
Mailing Address - Zip Code:89413-0110
Mailing Address - Country:US
Mailing Address - Phone:775-843-1754
Mailing Address - Fax:775-749-5021
Practice Address - Street 1:2163 PRAY MEADOW ROAD
Practice Address - Street 2:
Practice Address - City:GLENBROOK
Practice Address - State:NV
Practice Address - Zip Code:89413
Practice Address - Country:US
Practice Address - Phone:775-843-1754
Practice Address - Fax:775-749-5021
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5556208D00000X
NVDO630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E39865Medicare UPIN