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NPI Code Detail

MEDICARE: DR. WYATT JAFFE MD

MEDICARE: DR. WYATT JAFFE MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine PhysicianA79244CA
2207P00000XEmergency Medicine Physician036103047IL

General Provider Information

NPI Number : 1649293119
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. WYATT JAFFE MD
Provider Business Mailing Address
First Line : 768 MOUNTAIN RANCH RD
Second Line :
City : SAN ANDREAS
State : CA
Zip : 95249-9707
Country : US
Telephone Number : 209-754-2510
Fax Number :
Provider Business Practice Location Address
First Line : 768 MOUNTAIN RANCH RD
Second Line :
City : SAN ANDREAS
State : CA
Zip : 95249-9707
Country : US
Telephone Number : 209-754-2510
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2006
Last Update Date : 08/03/2021

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