Healthcare Provider Details

I. General information

NPI: 1972543676
Provider Name (Legal Business Name): JEFFREY A WACHS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2163 PRAY MEADOW ROAD
GLENBROOK NV
89413
US

IV. Provider business mailing address

PO BOX 110
GLENBROOK NV
89413-0110
US

V. Phone/Fax

Practice location:
  • Phone: 775-843-1754
  • Fax: 775-749-5021
Mailing address:
  • Phone: 775-843-1754
  • Fax: 775-749-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO630
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A5556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: