Provider Demographics
NPI:1821053422
Name:WUNDERLICH, JOANNE RUE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:RUE
Last Name:WUNDERLICH
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 1:1005 COMMERCIAL LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8149
Mailing Address - Country:US
Mailing Address - Phone:757-668-2600
Mailing Address - Fax:757-668-2620
Practice Address - Street 1:1005 COMMERCIAL LN
Practice Address - Street 2:SUITE 220
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8149
Practice Address - Country:US
Practice Address - Phone:757-668-2600
Practice Address - Fax:757-668-2620
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052372208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890629CMedicaid
VA370006854OtherRAILROAD MEDICARE
VA6712525Medicaid
VA6712525Medicaid
VA370000783Medicare PIN