Provider Demographics
NPI:1124010020
Name:WODNICKI, HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:WODNICKI
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 1:4306 ALTON RD
Mailing Address - Street 2:COMPREHENSIVE CANCER CENTER 2ND FLOOR
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2840
Mailing Address - Country:US
Mailing Address - Phone:305-674-2177
Mailing Address - Fax:305-674-2176
Practice Address - Street 1:4306 ALTON RD
Practice Address - Street 2:COMPREHENSIVE CANCER CENTER 2ND FLOOR
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2840
Practice Address - Country:US
Practice Address - Phone:305-674-2177
Practice Address - Fax:305-674-2176
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41122208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037435100Medicaid
04792Medicare ID - Type Unspecified
E19676Medicare UPIN