Provider Demographics
NPI:1427032481
Name:WANDER, DAVID S (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:WANDER
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 1:1304 RHAWN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2870
Mailing Address - Country:US
Mailing Address - Phone:215-742-1225
Mailing Address - Fax:215-742-3902
Practice Address - Street 1:1304 RHAWN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2870
Practice Address - Country:US
Practice Address - Phone:215-742-1225
Practice Address - Fax:215-742-3902
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002794-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0000670615Medicare NSC
PA0615750001Medicare NSC
T82174Medicare UPIN
PA078097Medicare PIN
NJ670615AL1Medicare PIN