Provider Demographics
NPI:1467895623
Name:WYDRA, FRANK B (MD)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:B
Last Name:WYDRA
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 1:100 E 14TH ST
Mailing Address - Street 2:APT 1809
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2889
Mailing Address - Country:US
Mailing Address - Phone:708-351-3634
Mailing Address - Fax:
Practice Address - Street 1:13001 E 17TH PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045
Practice Address - Country:US
Practice Address - Phone:303-724-2974
Practice Address - Fax:303-724-1593
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA152934207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program