Provider Demographics
NPI:1639114044
Name:WANDLER, BRUCE J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:J
Last Name:WANDLER
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:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:253-984-6774
Practice Address - Street 1:202 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4939
Practice Address - Country:US
Practice Address - Phone:253-804-2823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015369208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0200427OtherLABOR & INDUSTRY
WA1001066Medicaid
WA1001066Medicaid
WA0200427OtherLABOR & INDUSTRY