Provider Demographics
NPI:1295812063
Name:WLODEK, ROBERT MARK (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARK
Last Name:WLODEK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 ELKINS CIR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:702-436-3937
Practice Address - Street 1:9895 S MARYLAND PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-7165
Practice Address - Country:US
Practice Address - Phone:702-435-3937
Practice Address - Fax:702-436-3937
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV421152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002502054Medicaid
NV5171690001Medicare NSC
NVV38042Medicare ID - Type Unspecified