Provider Demographics
NPI:1639177496
Name:WLADIS, MARC P (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:P
Last Name:WLADIS
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 1:4 FURLONG CIR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-2144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-5293
Practice Address - Country:US
Practice Address - Phone:508-802-6770
Practice Address - Fax:508-802-6775
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-07-13
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
MA48096207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3010970Medicaid
MAA66374Medicare UPIN
MANX2813Medicare PIN