Provider Demographics
NPI:1619994472
Name:WODECKI, TADEUSZ K (MD)
Entity Type:Individual
Prefix:MR
First Name:TADEUSZ
Middle Name:K
Last Name:WODECKI
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 1:2256 ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087
Mailing Address - Country:US
Mailing Address - Phone:770-413-1300
Mailing Address - Fax:770-413-0547
Practice Address - Street 1:2256 ROCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087
Practice Address - Country:US
Practice Address - Phone:770-413-1300
Practice Address - Fax:770-413-0547
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029264207R00000X
NC200301312207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1619994472OtherNPI
GA00543397AMedicaid
GA00543397AMedicaid
GAD31417Medicare UPIN