Healthcare Provider Details

I. General information

NPI: 1881805331
Provider Name (Legal Business Name): TERRANCE DAVID WARDINSKY SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 BUTANO DRIVE
SACRAMENTO CA
95825-0447
US

IV. Provider business mailing address

411 EDGEWOOD DRIVE
VACAVILLE CA
95688-3604
US

V. Phone/Fax

Practice location:
  • Phone: 916-978-6263
  • Fax: 916-489-1380
Mailing address:
  • Phone: 707-446-6345
  • Fax: 916-489-1380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC043165
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: