Provider Demographics
NPI:1831102466
Name:WADSWORTH, REBECCA W (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:W
Last Name:WADSWORTH
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 1:6254 LAWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:14590-9792
Mailing Address - Country:US
Mailing Address - Phone:315-594-9444
Mailing Address - Fax:315-594-1315
Practice Address - Street 1:6254 LAWVILLE RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:NY
Practice Address - Zip Code:14590-9792
Practice Address - Country:US
Practice Address - Phone:315-594-9444
Practice Address - Fax:315-594-1315
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01217445Medicaid
NYD01761Medicare UPIN
NY01217445Medicaid