Healthcare Provider Details

I. General information

NPI: 1194761973
Provider Name (Legal Business Name): JONATHAN WAXMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9981 S HEALTHPARK DR STE 156
FORT MYERS FL
33908-3618
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-6341
  • Fax: 239-343-6342
Mailing address:
  • Phone: 239-343-6341
  • Fax: 239-343-6342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number38951
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME99916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: