Healthcare Provider Details

I. General information

NPI: 1508843384
Provider Name (Legal Business Name): JEFFREY S WALCZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3385 DEXTER CT SUITE 103
DAVENPORT IA
52807-3471
US

IV. Provider business mailing address

3385 DEXTER CT SUITE 103
DAVENPORT IA
52807-3471
US

V. Phone/Fax

Practice location:
  • Phone: 563-441-5860
  • Fax: 563-441-5865
Mailing address:
  • Phone: 563-441-5860
  • Fax: 563-441-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26742
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: