Provider Demographics
NPI:1104840826
Name:WASENKO, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:WASENKO
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 1:128 LAUREL LEDGE WAY
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-0539
Mailing Address - Country:US
Mailing Address - Phone:607-379-0259
Mailing Address - Fax:
Practice Address - Street 1:128 LAUREL LEDGE WAY
Practice Address - Street 2:
Practice Address - City:FLETCHER
Practice Address - State:NC
Practice Address - Zip Code:28732-0539
Practice Address - Country:US
Practice Address - Phone:607-379-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14650812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01198365Medicaid
300011040OtherRAILROAD MEDICARE
E20876Medicare UPIN
CC3539Medicare ID - Type Unspecified