Provider Demographics
NPI:1649270190
Name:WODECKI, BOB (MD)
Entity type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:WODECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:WODECKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:293 OLD MOCKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-1930
Mailing Address - Country:US
Mailing Address - Phone:704-872-8711
Mailing Address - Fax:704-872-5866
Practice Address - Street 1:293 OLD MOCKSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1903
Practice Address - Country:US
Practice Address - Phone:704-872-8711
Practice Address - Fax:704-872-5866
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36856207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988753Medicaid
NC4980030002OtherDMERC
NC8988753Medicaid
NC2188148EMedicare PIN