Healthcare Provider Details

I. General information

NPI: 1124010020
Provider Name (Legal Business Name): HENRY WODNICKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4306 ALTON RD COMPREHENSIVE CANCER CENTER 2ND FLOOR
MIAMI BEACH FL
33140-2840
US

IV. Provider business mailing address

4306 ALTON RD COMPREHENSIVE CANCER CENTER 2ND FLOOR
MIAMI BEACH FL
33140-2840
US

V. Phone/Fax

Practice location:
  • Phone: 305-674-2177
  • Fax: 305-674-2176
Mailing address:
  • Phone: 305-674-2177
  • Fax: 305-674-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME41122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: