Provider Demographics
NPI:1417199159
Name:WARDHAN, PRADEEP (MD)
Entity Type:Individual
Prefix:
First Name:PRADEEP
Middle Name:
Last Name:WARDHAN
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 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3261
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 E STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-483-3261
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI64706207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program