Provider Demographics
NPI:1710076617
Name:WACHENDORF, JUDITH M (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:WACHENDORF
Suffix:
Gender:F
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 9931
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-0931
Mailing Address - Country:US
Mailing Address - Phone:513-871-4682
Mailing Address - Fax:513-871-4682
Practice Address - Street 1:7201 ENGLISH DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45244-3147
Practice Address - Country:US
Practice Address - Phone:513-871-4682
Practice Address - Fax:513-871-4682
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059405208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0872499Medicaid
OHF18981Medicare UPIN
OH0872499Medicaid