Provider Demographics
NPI:1902844640
Name:WIRTH, CAROLE ZAJAC (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:ZAJAC
Last Name:WIRTH
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 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-738-6414
Mailing Address - Fax:717-738-6690
Practice Address - Street 1:169 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1724
Practice Address - Country:US
Practice Address - Phone:717-738-6414
Practice Address - Fax:717-738-6690
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036972E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012081670004Medicaid
PA300030336Medicare PIN
PA0012081670004Medicaid
PA612375Medicare PIN