Provider Demographics
NPI:1861545303
Name:WADDADAR, JAY (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:WADDADAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:2150 SE SALERNO RD
Practice Address - Street 2:STE 200
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6572
Practice Address - Country:US
Practice Address - Phone:772-223-5757
Practice Address - Fax:772-223-5789
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117635207RE0101X
NY209685207R00000X
WI50106-020207R00000X
LAMD.202234207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14T5JOtherFLORIDA BLUE
FL010232800Medicaid
FL010232800Medicaid