Provider Demographics
NPI:1063504637
Name:WAYAWOTZKI, JOHN (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WAYAWOTZKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776
Mailing Address - Country:US
Mailing Address - Phone:860-354-5537
Mailing Address - Fax:860-350-9340
Practice Address - Street 1:174 DANBURY RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776
Practice Address - Country:US
Practice Address - Phone:860-354-5537
Practice Address - Fax:860-350-9340
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0938152W00000X
CT000938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0719110001Medicare UPIN