Healthcare Provider Details

I. General information

NPI: 1205956265
Provider Name (Legal Business Name): KEVIN RICHARD WANDLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 POINTE PL
ROSWELL GA
30076-4636
US

IV. Provider business mailing address

888 S HILLHURST RD
RIDGEFIELD WA
98642-9063
US

V. Phone/Fax

Practice location:
  • Phone: 470-990-9483
  • Fax: 877-800-5436
Mailing address:
  • Phone: 754-300-3120
  • Fax: 954-306-8977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberDR.0055465
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number130525
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number2022048625
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD60562814
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number01092373A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number25MA10809300
License Number StateNJ
# 7
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number92660
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14421
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME110716
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number25MA10809300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: