Provider Demographics
NPI:1003025776
Name:WASIK, THEODORE PETER (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:PETER
Last Name:WASIK
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 1:29 ALBION PL
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1701
Mailing Address - Country:US
Mailing Address - Phone:617-470-1805
Mailing Address - Fax:617-714-5383
Practice Address - Street 1:61 ROSELAND ST STE 8
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3536
Practice Address - Country:US
Practice Address - Phone:617-470-1805
Practice Address - Fax:617-714-5383
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2437892084P0800X
PAMD4337912084P0800X
VA01012417192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry