Provider Demographics
NPI:1316039498
Name:WAFLART, THEODORE A (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:WAFLART
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:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-481-8493
Mailing Address - Fax:812-481-8497
Practice Address - Street 1:800 W 9TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2514
Practice Address - Country:US
Practice Address - Phone:812-481-5750
Practice Address - Fax:812-481-5763
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027456A207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10010907AMedicaid
IN10010907AMedicaid
IN192680AMedicare ID - Type UnspecifiedMEDICARE
IN137600BBBMedicare PIN