Provider Demographics
NPI:1053313767
Name:WANDEL, THADDEUS L (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:L
Last Name:WANDEL
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 1:136 OLD POST RD N
Mailing Address - Street 2:
Mailing Address - City:CROTON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10520-1934
Mailing Address - Country:US
Mailing Address - Phone:914-271-5026
Mailing Address - Fax:914-271-6592
Practice Address - Street 1:136 OLD POST RD N
Practice Address - Street 2:
Practice Address - City:CROTON ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10520-1934
Practice Address - Country:US
Practice Address - Phone:914-271-5026
Practice Address - Fax:914-271-6592
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098683207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00168263Medicaid
NY00168263Medicaid
NYB17545Medicare UPIN