Provider Demographics
NPI:1033313325
Name:WOJTALIK, ANN SUSAN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:SUSAN
Last Name:WOJTALIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2855 N KEYSTONE AVE
Practice Address - Street 2:100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-2789
Practice Address - Country:US
Practice Address - Phone:317-920-5760
Practice Address - Fax:317-920-5768
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050091A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200320740Medicaid