Provider Demographics
NPI:1346234614
Name:WASSERMAN, RICHARD LAWRENCE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LAWRENCE
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:MD, PHD
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE B-332
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-7788
Practice Address - Fax:972-566-8837
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4068207K00000X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX397487ZM3LOtherMEDICARE PTAN
TX1346234614Medicaid
TX940841OtherMEDICARE PTAN
TX120247505Medicaid
TX1202475-.03Medicaid
LA1756792Medicaid