Basic Information
| Provider Information | |||||||||
| NPI: | 1194761973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAXMAN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275321355 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 W DR MARTIN LUTHER KING JR BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132380810 | ||||||||
| FaxNumber: | 8132380811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | ME99916 | FL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 38951 | TN | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 209347905 | 05 | MO | MEDICAID | 8P057 | 01 | AR | GRP # | OTHER | 024508200 | 05 | FL | MEDICAID | 09016196 | 05 | MS | MEDICAID | 3339325 | 05 | TN | MEDICAID | 3713059 | 05 | TN | MEDICAID | 4095320 | 01 | TN | INDIVID # | OTHER | 62-1719735 | 01 | TN | TAX ID | OTHER | 99676 | 01 | AR | INDIVID # | OTHER | 159651001 | 05 | AR | MEDICAID | 02021708 | 05 | MS | MEDICAID |