Provider Demographics
NPI:1356394191
Name:WASICZKO, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WASICZKO
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 1:1656 CHAMPLIN AVE.
Mailing Address - Street 2:P.O.B., SUITE 335
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502
Mailing Address - Country:US
Mailing Address - Phone:315-624-4090
Mailing Address - Fax:315-624-4095
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-624-4090
Practice Address - Fax:315-624-4095
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183436208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01246377Medicaid
NY01246377Medicaid