Provider Demographics
NPI:1013909753
Name:WANDZILAK, THEODORE M (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:M
Last Name:WANDZILAK
Suffix:
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 1:1348 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1307
Mailing Address - Country:US
Mailing Address - Phone:502-634-8100
Mailing Address - Fax:502-637-6396
Practice Address - Street 1:1348 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1307
Practice Address - Country:US
Practice Address - Phone:502-634-8100
Practice Address - Fax:502-637-6396
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22152207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64221526Medicaid
KY1430501Medicare ID - Type Unspecified
0242010001Medicare NSC
KY64221526Medicaid