Healthcare Provider Details

I. General information

NPI: 1629291992
Provider Name (Legal Business Name): MICHAEL WADZINSKI, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 PIERCE ST SUITE 404
SIOUX CITY IA
51104-3759
US

IV. Provider business mailing address

PO BOX 3564
SIOUX CITY IA
51102-3564
US

V. Phone/Fax

Practice location:
  • Phone: 712-226-3937
  • Fax: 712-224-3973
Mailing address:
  • Phone: 712-226-3937
  • Fax: 712-224-3973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number29715
License Number StateIA

VIII. Authorized Official

Name: DR. MICHAEL GERARD WADZINSKI
Title or Position: PRESIDENT
Credential: MD
Phone: 712-226-3937