Individual
JACK WAXMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4015 QUARTZ DR, SANTA ROSA, CA 95405-5580
(707) 481-7215
Mailing address
4015 QUARTZ DR, SANTA ROSA, CA 95405-5580
(707) 481-7215
Taxonomy
Speciality
Code
Description
License number
State
207RR0500X
Rheumatology Physician
Primary
G23398
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G233980
BLUE SHIELD OF CALIFORNIA
CA
05
—
00G233980
—
CA
01
—
660002485
RAILROAD MEDICARE
CA
Enumeration date
07/14/2005
Last updated
03/27/2024
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