Healthcare Provider Details

I. General information

NPI: 1144285800
Provider Name (Legal Business Name): ALISON E. WONDRISKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 BICENTENNIAL HWY
SPRINGFIELD MA
01118-1962
US

IV. Provider business mailing address

305 BICENTENNIAL HWY
SPRINGFIELD MA
01118-1962
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-4101
  • Fax: 413-789-8047
Mailing address:
  • Phone: 413-733-4101
  • Fax: 413-789-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number72952
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3071162
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: