Provider Demographics
NPI:1407954324
Name:WACHA, ALBERT J (DPM)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:J
Last Name:WACHA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SMULL AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-5011
Mailing Address - Country:US
Mailing Address - Phone:973-226-4848
Mailing Address - Fax:973-226-7529
Practice Address - Street 1:31 SMULL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5011
Practice Address - Country:US
Practice Address - Phone:973-226-4848
Practice Address - Fax:973-226-7529
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00116900213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT44741Medicare UPIN
NJ194295Medicare PIN
NJ0813620001Medicare NSC