Provider Demographics
NPI:1346342391
Name:WACHENDORF, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:WACHENDORF
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 1:2804 W MARC KNIGHTON CT STE A
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-6301
Mailing Address - Country:US
Mailing Address - Phone:352-746-8000
Mailing Address - Fax:813-631-3917
Practice Address - Street 1:2804 W MARC KNIGHTON CT STE A
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-6301
Practice Address - Country:US
Practice Address - Phone:352-746-8000
Practice Address - Fax:813-631-3917
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067899207R00000X
IN01044562A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F73343Medicare UPIN