Provider Demographics
NPI:1275502171
Name:WADIWALA, ISMAIL (MD)
Entity Type:Individual
Prefix:
First Name:ISMAIL
Middle Name:
Last Name:WADIWALA
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 1:210 N FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4725
Mailing Address - Country:US
Mailing Address - Phone:209-823-1121
Mailing Address - Fax:209-823-0393
Practice Address - Street 1:210 N FREMONT ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4725
Practice Address - Country:US
Practice Address - Phone:209-823-1121
Practice Address - Fax:209-823-0393
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42925207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA82861Medicare UPIN