Provider Demographics
NPI:1861456105
Name:WIRTH, JOHN C III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:WIRTH
Suffix:III
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 1:225 BROADWAY
Mailing Address - Street 2:SUITE 901
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-3001
Mailing Address - Country:US
Mailing Address - Phone:212-393-9400
Mailing Address - Fax:212-393-9405
Practice Address - Street 1:225 BROADWAY
Practice Address - Street 2:SUITE 901
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-3001
Practice Address - Country:US
Practice Address - Phone:212-393-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209892-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01810457Medicaid
F89230Medicare UPIN
NY01810457Medicaid