Provider Demographics
NPI:1144213265
Name:WADSWORTH, HARRY L (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:L
Last Name:WADSWORTH
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 1:26 NANTUCKET LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 100B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-432-1111
Practice Address - Fax:314-432-6308
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7P48207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO24916OtherBC/BS
MO148998OtherHEALTHLINK
MO47310OtherGHP
MO110054267OtherRR MEDICARE
MO24916OtherBC/BS
MO015010612Medicare ID - Type Unspecified