Healthcare Provider Details

I. General information

NPI: 1760555254
Provider Name (Legal Business Name): ROBERT RICHARD WRESCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 YPAO RD
TAMUNING GU
96913-3701
US

IV. Provider business mailing address

388 YPAO RD
TAMUNING GU
96913-3701
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-8881
  • Fax: 671-648-2557
Mailing address:
  • Phone: 671-646-8881
  • Fax: 671-648-2557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberM000934
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: