1275525248 NPI number — DR. PUSHKAR S WADGAONKAR MD

Table of content: DR. PUSHKAR S WADGAONKAR MD (NPI 1275525248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275525248 NPI number — DR. PUSHKAR S WADGAONKAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADGAONKAR
Provider First Name:
PUSHKAR
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275525248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1208 BEALL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRAL POINT
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97502-1573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-664-5151
Provider Business Mailing Address Fax Number:
541-664-5155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 E BARNETT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-8332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-608-4700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  MD25465 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 277943 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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